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Tag: scale

  • Knowing-in-action: Bridging the theory-practice divide in global health

    Knowing-in-action: Bridging the theory-practice divide in global health

    The gap between theoretical knowledge and practical implementation remains one of the most persistent challenges in global health. This divide manifests in multiple ways: research that fails to address practitioners’ urgent needs, innovations from the field that never inform formal evidence systems, and capacity building approaches that cannot meet the massive scale of learning required. Donald Schön’s seminal 1995 analysis of the “dilemma of rigor or relevance” in professional practice offers crucial insights for “knowing-in-action“. It can help us understand why transforming global health requires new ways of knowing – a new epistemology.

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    Schön’s analysis: The dilemma of rigor or relevance

    Schön begins by examining how knowledge becomes institutionalized through education. Using elementary school mathematics as an example, he describes how knowledge is broken into discrete units (“math facts”), organized into progressive modules, assembled into curricula, and measured through standardized tests. This systematization shapes not just content but the entire organization of time, space, and institutional arrangements.

    From this foundation, Schön introduces his central metaphor of two contrasting landscapes in professional practice that prevent “knowing-in-action”. As he describes it:

    “In the varied topography of professional practice, there is a high, hard ground overlooking a swamp. On the high ground, manageable problems lend themselves to solution through the use of research-based theory and technique. In the swampy lowlands, problems are messy and confusing and incapable of technical solution.”

    The cruel irony, Schön observes, lies in the relative importance of these terrains: “The problems of the high ground tend to be relatively unimportant to individuals or to society at large, however great their technical interest may be, while in the swamp lie the problems of greatest human concern.”

    This creates what Schön calls the “dilemma of rigor or relevance” – practitioners must choose between remaining on the high ground where they can maintain technical rigor or descending into the swamp where they must rely on experience, intuition, and what he terms “muddling through.”

    The historical roots of the divide

    Schön traces this dilemma to the epistemology embedded in modern research universities. Drawing on Edward Shils’s historical analysis, he describes how American scholars returning from Germany after the Civil War brought back “the German idea of the university as a place in which to do research that contributes to fundamental knowledge, preferably through science.”

    This was, as Schön notes, “a very strange idea in 1870,” running counter to the prevailing British model of universities as sanctuaries for liberal arts or finishing schools for gentlemen. The new model first took root at Johns Hopkins University, whose president embraced the “bizarre notion that professors should be recruited, promoted, and granted tenure on the basis of their contributions to fundamental knowledge.”

    This shift created what Schön terms the “Veblenian bargain” (named after Thorstein Veblen), establishing a separation between:

    • Research universities focused on “true scholarship” and fundamental knowledge
    • Professional schools dedicated to practical training

    Knowing-in-action in global health: From fragmentation to integration

    The historical division between theory and practice that Schön identified continues to shape global health in profound and often problematic ways. This manifests in three interconnected challenges that demand our urgent attention: the knowledge-practice gap, the scale challenge, and the complexity challenge. Yet emerging approaches suggest potential paths forward, particularly through structured peer learning networks that could help bridge Schön’s “high ground” and “swamp.”

    Three fundamental challenges

    Challenge #1: The knowing-in-action divide

    The separation between research institutions and field practice creates not just an academic concern but a practical crisis in healthcare delivery. Consider the response to COVID-19: while research institutions rapidly generated new knowledge about the virus, frontline health workers struggled to translate this into practical approaches for their specific contexts. Their hard-won insights about what worked in different settings rarely made it back into formal evidence systems, epitomizing the one-way flow of knowledge that impoverishes both research and practice.

    This pattern repeats across global health. Research agendas, shaped by academic incentives and funding priorities, often fail to address practitioners’ most pressing challenges. A community health worker in rural Bangladesh facing complex challenges around vaccine hesitancy may struggle to find relevant guidance – while global experts are convinced that they already have all the answers. Meanwhile, local solutions to building vaccine confidence remain uncaptured by formal knowledge systems.

    The rise of implementation science attempts to bridge this divide, yet often remains subordinate to “pure” research in academic hierarchies. This reflects Schön’s observation about the privileging of high ground problems over swampy ones, even when the latter hold greater practical significance.

    Challenge #2: The scale imperative

    Traditional approaches to professional education face fundamental limitations in meeting the massive need for health worker capacity building. The World Health Organization projects a shortfall of 10 million health workers by 2030, mostly in low- and middle-income countries. Conventional training approaches that rely on cascading knowledge through workshops and formal courses can reach only a fraction of those who need support.

    More fundamentally, these knowledge transmission models prove inadequate for addressing complex local realities. A standardized curriculum developed by experts, no matter how well-designed, cannot anticipate the diverse challenges health workers face across different contexts. When a district immunization manager in Nigeria must adapt vaccination strategies for nomadic populations during a drought, they need more than pre-packaged knowledge – they need ways to learn from others who are facing similar challenges.

    Resource constraints further limit the reach of conventional approaches. The cost of traditional training programmes, both in money and time away from service delivery, makes it impossible to scale them to meet the need. Yet the human cost of this capacity gap, measured in preventable illness and death, demands urgent solutions.

    Challenge #3: The complexity conundrum

    Contemporary global health faces challenges that fundamentally resist standardized technical solutions. Climate change exemplifies this complexity, creating cascading effects on health systems and communities that cannot be addressed through linear interventions. When rising temperatures alter disease patterns while simultaneously disrupting cold chains for vaccine delivery, no single technical fix suffices.

    Similarly, emerging and re-emerging infectious diseases demand responses that cross traditional boundaries between animal and human health, environmental factors, and social determinants. Health workforce development must grapple with complex systemic issues around motivation, retention, and capacity building. The COVID-19 pandemic demonstrated how traditional approaches to health system strengthening often prove inadequate in the face of complex adaptive challenges.

    Emerging solutions: A new paradigm for learning and practice

    Recent innovations suggest promising approaches to bridging these divides through structured peer learning networks. Digital platforms enable health workers to share experiences and solutions across geographical boundaries, creating new possibilities for scaled learning that maintains local relevance.

    Solution #1: The power of structured peer learning

    Experience from digital learning networks demonstrates how structured peer interaction can enable more efficient and effective knowledge sharing than traditional top-down approaches. When health workers can directly connect with peers facing similar challenges, they not only share solutions but collectively generate new knowledge through their interactions.

    These networks provide mechanisms for validating practical knowledge through peer review processes that complement traditional academic validation. A successful intervention developed by a rural clinic in Thailand can be critically examined by peers, adapted for different contexts, and rapidly disseminated across the network. This creates a more dynamic and responsive knowledge ecosystem than traditional publication cycles allow.

    Solution #2: Network effects and collective intelligence

    The potential of practitioner networks extends beyond simple knowledge sharing. When properly structured, these networks create possibilities for:

    1. Rapid adaptation to emerging challenges through real-time sharing of experiences
    2. Collective problem-solving that draws on diverse perspectives and contexts
    3. Systematic capture and analysis of field innovations
    4. Development of context-specific solutions that build on shared learning

    Most importantly, these networks can help bridge Schön’s high ground and swamp by creating dialogue between different forms of knowledge and practice. They provide spaces where academic research can inform field practice while simultaneously allowing field insights to shape research agendas.

    Four principles toward knowing-in-action for global health

    Drawing on Schön’s call for a “new epistemology,” we can identify four principles for transforming how we know what we know in global health:

    Principle #1: Valuing multiple forms of knowledge

    The complexity of contemporary health challenges demands recognition of multiple valid forms of knowledge. The practical wisdom developed by a community health worker through years of service deserves attention alongside randomized controlled trials. This requires challenging existing hierarchies of evidence while maintaining rigorous standards for validating knowledge claims.

    Principle #2: Enabling knowledge creation from practice

    Health workers must be supported as knowledge producers, not just knowledge consumers. This means creating structures for systematically capturing and validating field insights, building evidence from implementation experience, and enabling continuous learning from practice. Digital platforms can provide scaffolding for this knowledge creation while ensuring quality through peer review processes.

    Principle #3: Scaling through networked learning

    Traditional scaling approaches that rely on standardization and top-down dissemination must be complemented by networked learning to create and amplify knowing-in-action. This means building systems that can:

    1. Connect practitioners across contexts and boundaries
    2. Enable peer validation of knowledge
    3. Support rapid dissemination of innovations
    4. Build collective intelligence through structured interaction

    Principle #4: Embracing complexity

    Rather than seeking to reduce complexity through standardization, health systems must build capacity for working effectively within complex adaptive systems. This means supporting adaptive learning, enabling context-specific solutions, and building capacity for systems thinking at all levels.

    The challenges facing global health today demand new ways of creating, validating, and sharing knowledge. By embracing approaches that bridge Schön’s high ground and swamp, we may find paths toward health systems that are both more rigorous and more relevant to the communities they serve.

    Looking forward

    Schön’s analysis helps explain why traditional approaches to global health knowledge and learning often fall short. More importantly, it points toward solutions that could help bridge the theory-practice divide to support knowing-in-action:

    1. New digital platforms that enable peer learning at scale
    2. Networks that connect practitioners across contexts
    3. Approaches that validate practical knowledge
    4. Systems that support rapid learning and adaptation

    Schön’s insights remain remarkably relevant to contemporary global health challenges. His call for a new epistemology that can bridge theory and practice speaks directly to our current needs. By embracing new approaches to learning and knowledge creation that honor both rigor and relevance, we may find ways to address the complex challenges that lie ahead.

    The key lies not in choosing between high ground and swamp, but in building new kinds of bridges between them – bridges that can support the massive scale of learning needed while maintaining the local relevance essential for impact. Recent innovations in peer learning networks and digital platforms suggest this bridging may be increasingly possible, offering hope for more effective global health practice in an increasingly complex world.

    The challenge now is to develop and implement these bridging approaches at the scale needed to support global health workers worldwide. This will require new ways of thinking about knowledge, learning, and practice – ways that honor both the rigor of research and the wisdom of experience. The future of global health may depend on our success in this endeavor.

    Listen to the AI podcast deep dive about this article

    Reference

    Schön, Donald A., 1995. Knowing-in-action: The new scholarship requires a new epistemology. Change: The Magazine of Higher Learning 27, 27–34. https://doi.org/10.1080/00091383.1995.10544673

    Image: The Geneva Learning Foundation Collection © 2024

  • Pandemic preparedness through connected transnational digital networks of local actors

    Pandemic preparedness through connected transnational digital networks of local actors

    What is the link between pandemic preparedness, digital networks, and local action? In the Geneva Learning Foundation’s approach to effective humanitarian learning, knowledge acquisition and competency development are both necessary but insufficient. This is why, in July 2019, we built the first Impact Accelerator, to support local practitioners beyond learning outcomes all the way to achieving actual health outcomes.

    What we now call the Full Learning Cycle has become a mature package of interventions that covers the full spectrum from knowledge acquisition to implementation and continuous improvement. This package has produced the same effects in every area of work where we have been able to test it: self-motivated groups manifesting remarkable, emergent leadership, connected laterally to each other in each country and between countries, with a remarkable ability to quickly learn and adapt in the face of the unknown. Such networks have obvious relevant for pandemic preparedness.

    In 2020, we got to test this package during the COVID-19 pandemic, co-creating the COVID-19 Peer Hub with over 6,000 frontline health professionals, and building together the Ideas Engine to rapidly share ideas and practices to problem-solve and take action quickly in the face of dramatic consequences of the new virus on immunization services (largely due to fear, risk, and misinformation). By January 2021, over a third of Peer Hub members had successfully implemented their immunization service recovery project, far faster than colleagues who faced the same problems but worked alone, without a global support network. Once connected to each other, these country teams then organized inter-country peer learning to help them figure out “what works” for COVID-19 vaccine introduction and scale-up.

    Such a holistic approach is about mobilizing and connecting country-based impact networks for pandemic preparedness that reach and involve practitioners at the local levels, as well as national MoH leaders and planners – quite different from conventional approaches (whether online or face-to-face) to building capacity and preparedness.

    TGLF’s global health network and platform reach significant numbers of practitioners at all levels of the health system. It is not only the number of people who participate (47,000 as I write this) but also the depth of engagement and diversity of contexts that they work in. Globally, 21.2% face armed conflict; 24.5% work with refugees or internally-displaced populations; 61.6% work in remote rural; 47% with the urban poor; 35.7% support the needs of nomadic/migrant populations. This is across 110 countries, with over 70 percent in “high burden” countries. Many have deep experience in responding to epidemic outbreaks of all kinds. Health professionals who join come from all levels of the health system, but most are (logically) from health facilities and districts, the bottom of the health pyramid.

    Through the network and platform, they build lateral connections, forging bonds not only of knowledge but also of trust. They do this not because they are from the same profession, but primarily (we believe) because they face similar challenges and see the benefit of sharing their experience in support of each other. Engagement is voluntary (ie people opt in and contribute because they want to), with no per diem or other extrinsic incentives offered. The concern for both epidemic outbreak and pandemic preparedness is shared.

    Individuals develop and implement corrective actions to tackle the root causes of the challenges they are taking on, drawing on both peer learning and the best available global guidelines. For the IA2030 Movement, our largest initiative so far, participants are simultaneously implementing 1,024 projects in 99 countries, learning from each other what works, sharing successes, lessons learned, and challenges. Here are four examples of what collective action through digital networks looks like :

    • In Ghana, TGLF’s alumni (including national and regional MoH EPI directors) decided to organize online sessions country-wide to share the latest information about COVID-19 with local staff, starting in April 2020. They had learned how to use digital tools to find the best available global knowledge and to combine it with their local expertise and experience to inform collective action.
    • In Burkina Faso, the national EPI manager entrusted the first “masked” vaccination campaign to the TGLF alumni team, which has organized itself country-wide, with over half of alumni working in conflict-affected areas. He told me no one else had the network and the capacity for change to figure out quickly how to get this right.
    • In the Democratic Republic of Congo, the TGLF alumni team is increasingly being asked by national EPI to contribute to various activities, due to their effectiveness in connecting and coordinating. The alumni network is country-wide and includes many from very remote areas. When Monkeypox was reported in Europe and North America, we were already seeing a steady stream of information through the DRC and other country networks.

    We believe that this continuous learning and action is actually the definition of pandemic preparedness. Trying to imagine preparedness and response to new pandemics using old, failed methods of training and capacity building – whether face-to-face or online – is both dangerous and irrational.

    Image: Remote villages illuminated by rays of light, with mountains beyond mountains in the background. The Geneva Learning Foundation Collection.

  • Missed opportunities (1): making a dent requires rethinking how we construct medical education

    Missed opportunities (1): making a dent requires rethinking how we construct medical education

    “We are training 30 people to become doctors. My focus is on developing content for open educational resources (OER) that we can use to transmit foundational knowledge.”

    Training 30 people at a time is not going to make a dent. Cost and scale are related. Quality does not need to diminish against lower cost or higher scale.

    OER are obviously about producing knowledge, but seldom question agency in epistemology. How do we know what know? Who knows how we know? Is the democratization of learning about producing new resources by conventional means, albeit in an African context in partnership with a U.S. university?

    I realize then that we understand the content trap in very different ways. For me, it is avoided by embracing pedagogical transformation from transmission to knowledge co-construction. The trap is to remain mired in transmissive modes in a world of content abundance. For various reasons, some people cannot see this distinction or its significance.

    “Imagine if you could convene 1,000 doctors,” I say, “to take this foundational knowledge and develop localized guides, grounded in their indigenous expertise. In four weeks, they would produce hundreds of high-quality, peer-reviewed guides with the synthesis of their collective, practical experience of how to challenge health inequity in practice, in situ…”

    They know what others do not know. Imagine connecting medical students to such a global network of practitioners who find it immoral that they can only treat those who can pay – and who are already doing something about it. The standard of care may be the same everywhere, but how you drive change to achieve it is so dependent on context. Surely, he will grasp how transformative this could be?

    “You may want to speak to our colleagues who do in-service training. They do a lot of that. They may have a real interest in what you are doing here.”

    We have already done this with topics completely disparate from each other: pre-hospital emergency care, safer access for humanitarian teams, immunization… But this confuses those who still think in silos of subject matter expertise. There is no topic specificity to what I am proposing. Yes, my proposal breaks with the conventions of medical education. You do not connect students to global action networks. You confine them in a controlled environment to train them, tell them what they must do and how they must do it in order to avoid killing people who are sick, and ensure that they can recall (or look up) the information they need to do this without you.

    Is that really all that we can do? Is that really all that must be done?

    He ends by boasting how the new campus will have fiber optic. By this point, I can only smile wrily. Fiber enables two-way knowledge flows. Ideological or epistemological limitations confine us to using only half of this potential.

    Changing medical education is more than changing locale, revising enrollment criteria, producing “free” resources (subsidized by university endowments), or considering political economy as part of medicine. It requires a change in education as a philosophy.

    Image: Mother and child. Fountain on the roundabout, Kigali Convention Centre, Rwanda (personal collection)

  • Complexity and scale in learning: a quantum leap to sustainability

    This is my presentation on 19 June 2014 at the Scaling corporate learning online symposium organized by George Siemens and hosted by Corp U.

  • A question of such immense and worldwide importance

    A question of such immense and worldwide importance

    Scale: Predictions over the impact of climate change and globalization suggest that we will see more frequent disasters in a greater number of countries, along with more civil unrest in those states less able to cope with this rapidly changing environment, all generating a greater demand for humanitarian and development assistance (cf. Walker, P., Russ, C., 2012. Fit for purpose: the role of modern professionalism in evolving the humanitarian endeavour. International Review of the Red Cross 93, 1193–1210.)

    Complexity: The world’s problems are characterized by volatility, uncertainty, and complexity in a knowledge society. The industry to tackle these growing challenges has expanded rapidly to become increasingly professionalized, with a concentrated number of global players increasingly focused on the professionalization of more than 600,000 paid aid workers and over 17 million volunteers active worldwide in UN agencies, the Red Cross and Red Crescent Movement, and the main international non governmental organizations (INGOs).

    Innovation: The scale and complexity of humanitarian and development issues call for doing new things in new ways. The skills and processes that will prepare the humanitarian workers of tomorrow are not yet embedded in our educational structures. In fact, education is failing to prepare humanity for the challenges of the future. Existing partnerships do not address this gap. Attempting to do more of what has been done in the past is not the answer. No single organization can solve a question of such immense and worldwide importance. It is the future of humanity that is at stake.

    Photo credit: NASA/Bill Ingalls via flickr.com

  • There is no scale

    There is no scale

    So, you are unhappy with a five percent completion rate. Hire tutors (lots of them, if it is massive). Try to get machines to tutor. Use learners as tutors (never mind the pedagogical affordances, you only care about scale and completion). Set up automated phone calls to remind people to turn in their homework. Ring the (behaviorist) bell.

    Or not.

    Google’s Coursebuilder team has an interesting take on completion rates. Let’s start by asking learners what they want to achieve. Then examine their behavior against their own expectations, rather than against fixed criteria. Surprise, surprise: take learner agency into consideration, and it turns out that most folks finish… what they wanted to.

    Bill Cope has an interesting take on scale. He says: there is no scale. It is not only that face-to-face/online is a false dichotomy. The intimacy of learning can be recreated, irregardless of how many people are learning. Public schools break down an entire population of children into classes of twenty-five. The Red Cross and Red Crescent train 17 million people each year to do first aid, one workshop at a time. That makes the best aspects of those experiences ‘personable’. But depersonalization is not  a function of scale. It is a function of learning environments that limit the affordances of learning and assessment.

    In the United States, 26 million already have Type II diabetes. That is already massive problem on a national scale, part of the very wicked problem that makes non-communicable diseases the world’s bigger killer, responsible for over 36 million deaths every year. Prevent is a start-up that just raised 28 million U.S. dollars to deliver personalized health education on the very intimate issue of pre-diabetes, where a positive outcome equals a change in real-world behavior. In its model, each person is matched to a small (read: personable) group of no more than a dozen peers, and then works as part of this small group. The first published clinical study (apparently sponsored by the start-up, but due for publication in a scientific journal) indicates that the approach helps people lose weight in clinically-significant, long-term ways. The scale is in the opportunity, not in the experience of Prevent participants.

    There is no scale.