Executive Summary

Learning – at individual, team, organization and cross-organization levels – is fundamental to health systems strengthening and the achievement of health goals. Yet, many health systems, especially in low-and middle-income countries (LMICs), still do not have adequate capacity to generate and use the knowledge that they need to be effective. Investments in learning activities tend to be a remarkably small proportion of overall investments in health programmes and systems, and learning-focused activities have historically not found place or favour in budgets when compared with other health system priorities.

Why is learning so neglected? One explanation is that the many pressures on health systems crowd out the “softer” work of learning, which is perceived as having less immediate or predictable benefits. Another is that the conceptualization of a learning health system, its benefits and how it can be built have not been well articulated. This report, therefore, makes the case for such systems.

The report draws on theories of learning organizations and system learning to help understand how learning occurs in health systems. Health systems are complex, adaptive and people-centred, with multiple functions that have the ultimate purpose of improving health. Learning in health systems occurs at many interconnected levels – individual, group or team levels, and at organizational and cross-organizational levels. It is characterized by three distinct learning loops – single, double and triple – and occurs through three interconnected means: information, deliberation and action.

LEARNING LEVELS

Learning at the individual level entails information-gathering from different sources, gaining knowledge through experience, and interpreting the knowledge acquired. Health providers and managers in LMICs, for example, draw on data from health information systems and on research evidence as well as their own information about their staff, facility and community contexts. In contrast, team and group-level learning tends to involve the collective interpretation of knowledge through dialogue and exchange, and the development of shared understanding about problems and solutions. Learning at individual and team levels is not, however, enough to influence learning at organization- and cross-organization levels. This requires the routine integration of knowledge and understanding to facilitate wider coordinated action. 

LEARNING LOOPS

The aims and results of learning depend on the type of learning ‘loop’: single, double or triple. Single-loop learning can support changes in regular actions by adapting normal routines and practices, but tends to overlook the assumptions on which these are based. 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. Triple-loop learning, often referred to as “learning how to learn”, challenges fundamental assumptions and improves the way in which the system learns. 

MEANS OF LEARNING

Learning through information includes collecting and processing information, as well as taking steps for its deployment and dissemination. Common sources for health systems include routine health-information systems data, primary and secondary research, organizational documentation and community feedback. The resulting information can be used to inform routine or strategic decisions within the health system, for training and capacity-building, and for dissemination.  

Learning through deliberation is essential to link past actions, their impact, and actions in the future. It also contextualizes problems and supports collective understanding on solutions. Within health systems, deliberation includes stakeholder consultations, collaborations and community and public engagement. The learning generated through such processes amounts to more than the sum of individual knowledge, as it is enriched by collective knowledge and insights. 

Learning through action occurs when people learn through the practice and repetition of tasks and projects. Such learning often generates innovations and good practices that can be shared with other actors within or beyond the health system.

How learning occurs in health systems – three dimensions

First, learning improves health systems functions at all levels, enabling individuals, teams and organizations to enhance their regular practices and, therefore, perform their functions more effectively. Health systems that are informed by past experiences, deliberations and diverse sources of information are better equipped to adjust and modify their regular actions. 

Second, learning supports adaptation and innovation. In an ever-changing world, the ability of health systems to anticipate and respond to change is crucial. Learning health systems that draw on available knowledge and recognize and correct mistakes are better placed to adapt their actions to meet contextual changes. Health systems that innovate successfully are often those that welcome experimentation and assess innovations for future use and scaling up. 

Third, learning supports self-reliance. Learning health systems can set their own priorities, define their own frameworks for action, and optimize their use of existing resources, as they are less dependent on external actors. 

INSTITUTIONALIZING LEARNING

Institutionalization entails setting rules and establishing procedures conducive to learning at organization and cross-organization levels.  Several measures can be taken to institutionalize learning through information. The consistent use of routine data to help guide decisions in the health system, for example, requires mainstreaming data aggregation and deployment across health system policy and service delivery. The integration of monitoring and evaluation (M&E) into different aspects of health system operations is another important step. 

The use of research evidence is institutionalized by formalizing collaborative links between researchers and health system decision-makers through embedded research approaches, or by establishing policy research institutes. In some instances, specialized intelligence units may be established to help set priorities for action and investment (e.g. health technology assessment platforms), advance thinking on strategic areas (e.g. behaviour change research units), or to address priority problems (e.g. emergency prediction and response cells).

Institutionalizing deliberative learning entails different measures. Working groups and inter-ministerial committees are common examples of mechanisms to enhance understanding and promote consensual action across the health sector and other sectors. Deliberative platforms for community engagement and participatory planning, such as local health councils, are rich sources of learning from and with citizens and users of services. Communities of practice, including those using social media, can enable rapid discussion and solution-sharing among peer groups of health managers, planners or practitioners. 

Finally, institutionalizing experiential learning involves such measures as setting up pilot schemes, learning sites and practice and innovation labs, with the potential to identify promising practices and scale up or diffuse innovations to other settings and across systems. 

OPTIMIZING PEOPLE’S LEARNING CAPACITY

Building a learning health system also requires creating human skills and capacities to learn through formative or continuing education and using them effectively by engaging them in appropriate roles within the health system. 

Health care providers, health managers and policy-makers, for example, need to be enabled to develop a range of relevant learning capacities, including  interpreting routine data, synthesizing evidence, using the findings of M&E, team and participatory learning, identifying and scaling up innovations, and communication and knowledge management. 

At the same time, strengthening the capacities of communities, citizens and users of health services facilitates their contributions to learning and includes health literacy. This means going beyond sharing public information on health services, rights and protections to develop the capacity of the public – particularly those from disadvantaged groups to engage with health systems in a meaningful way. 

Building a learning health system also needs a critical mass of researchers and analysts who can contribute expertise and generate evidence on health systems and policy, as well as in specialized or strategic health system functions, and in non-technical skills such as working effectively with non-academic partners. It is crucial that the contributions of researchers are incentivized and aligned to health system priorities though relevant employment opportunities and funding. 

Finally, it is also important to nurture and develop the teachers, trainers, mentors and methodologists who will help develop capacities in these different learning arenas and continue to improve learning approaches in response to the evolving needs of health systems. 

CREATING THE CONDITIONS FOR LEARNING

Leadership and culture are interdependent factors, both of which are vital for the development of a vision for learning, the establishment of learning structures and processes, and to spur collective action across organizations or systems to identify and solve problems. A culture that is conducive to learning is characterized by teamwork and cooperation, openness to experimentation and mistakes, and an appreciation of differences and inclusivity. 

System design can enable or constrain learning, with the quality of learning shaped by processes for governance and accountability, quality improvement, the deployment and mobility of personnel, priority setting and planning, communication, supervision and incentives. In a learning health system an active learning agenda and vision needs to be embedded in system design. 

Learning health systems need the stable and long-term investment of financial resources. These need to cover the costs of establishing and sustaining the diverse mechanisms for institutionalized learning, and also of developing and deploying human capacities for learning effectively. 

The learning needs of health systems are deeply contextual, with no single blueprint or framework. Even so, those needs are urgent and demand immediate action by key stakeholders. 

Health policy-makers and planners can take the lead by developing and implementing a learning strategy for the health system, support it through a framework to track progress, and back it with the necessary resources. They are also best placed to strengthen the institutionalization of learning at all levels of the health system; ensure that it absorbs, deploys and retains people and teams with relevant learning capacities; and help strengthen the learning capacities of in-service personnel.

Health programmes and health workers can strengthen team-based learning and on-the-job mentoring, establish learning sites and participatory learning initiatives, and develop communities of practice and solution-sharing platforms.

Community representatives and civil society organizations can strengthen platforms for participatory planning and governance, amplify the voices of citizens and service users, and participate in and drive shared learning. 

Research leaders and organizations can collaborate with policy-makers to establish platforms for policy and systems research, as well as evidence synthesis and use to meet knowledge needs. Research councils and universities can widen their focus to include interdisciplinary and applied policy and systems research, building research capacity in these areas to meet the learning needs of health systems. 

Educational councils and professional training institutes can build the capacities of future health professionals and health-sector personnel in key learning areas, including M&E, data management, communication and knowledge management, research methods and evidence use, innovation management, participatory learning and team-based learning. 

To paraphrase a well-known saying: a system that does not learn from history is condemned to repeat it. Learning is a forward-looking and actionable lens through which to view the agenda of strengthening health systems. Ultimately, learning represents a means for progress and empowerment for health systems - especially those in low- and middle-income countries – by developing the inbuilt ability to generate and use the knowledge and skills they need to constantly improve and perform.