8 key messages about how lessons spread between countries

In 2000, the World Health Organisation attempted something incredibly ambitious. It attempted to rank the total health system efficiency for each of its 191 member countries. It wanted to say, given the resources available, which system was performing best and which was performing worst. It did this by comparing health expenditure per capita to a combination of outcomes, responsiveness, financing sources, and equity. The idea was to encourage healthy competition (pun intended), but also to identify strong performers, from whom lessons could be learnt.

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Since then, the internet has transformed the accessibility of information. With this, what has happened to the idea of countries learning from each other as they build their health systems?

Over the past 18 months I have managed a project to understand what, why and how (if at all) lessons spread between health systems in sub-Saharan Africa, and what external funding agencies could do to help.

We asked policy stakeholders (such as politicians, ministers, civil servants), academics (those researching health systems), and people working for international organisations (such as the World Bank, WHO, and bilateral donors) about their views and relevant experience on this topic. This was complemented with eight country case studies. We looked at actual long-term reforms, such as the Health Extension Programme in Ethiopia, to unpack the role that learning from other countries might have actually played. In this post, I outline eight of the overarching points that emerged, to help us understand what may be needed to realise that WHO ambition from nearly 20 years ago.

1. There is a demand from policy stakeholders in sub-Saharan Africa for a better regional coordination mechanism that facilitates learning between countries.

In practice, this means linking countries that are likely to have something to learn from each other. For example, a mechanism that could observe that one country is struggling with a certain aspect of its drugs supply chain, and that another country recently managed to implement solutions to a similar problem. At present, many countries are facing challenges that other countries have recently battled, but neither knows of it.

2. Policy stakeholders struggle to navigate the complex body of research, data, and lessons, and communities of practice, that already exists.

We started the project by trying to map all of the existing platforms that try to help countries learn from each other. We got to 170 and realised we weren’t even close to finishing. Policy stakeholders often don’t know where to start. Simple questions like ‘which network is useful for me?’, ‘how do I use a community of practice?’, and ‘which databases can I trust?’ are difficult to answer. Without the time to inform themselves, they simply stop looking.  Because of this, there is a common desire for a trusted ‘one-stop-shop’ for quality vetted information about other countries and best practices. Whether realisable or not, the demand is clear.

3. Policy stakeholders would like more information about ‘how’ rather than ‘what’.

Most of the information policy stakeholders say they are currently able to find is about what other countries have done, what the results were, and, in turn, suggestions about what policies they should implement. In fact, what keeps policy stakeholders up at night is not ‘what policies to implement’, but ‘how to implement the policies they have’. There is much less information available about this.

4. The model of a ‘teaching’ country and a ‘learning’ country is not attractive.

No country’s policy stakeholders want to feel inferior to those in another country. Similarly, policy stakeholders are less willing to put in the time to tell others about their experience and insights if they feel they aren’t getting anything in return. Wherever possible, learning environments should recognise that information can flow in two directions at once.

5. Most of the instances of cross-border evidence flow we witnessed were mediated by trusted brokers.

Trust and personal relationships are incredibly important ingredients in the ‘learning across countries’ process. Where it was clear that lessons had crossed borders, it was often possible to identify a small number of specific individuals who played central and long-term roles in the transfer. They were close enough to the decision-making powers over a long enough period to build trust and had prior personal knowledge of the international information.

6. There is a need to build confidence in the relevance of other countries’ experience.

Policy stakeholders tend to have an in-depth understanding of one place – that in which they work. The simple reality is that they may not know much at all about any other health systems. Most people who advocate for learning from other countries, on the other hand, have an international focus. They often know a bit about many places, but may not have an in-depth understanding of anywhere.  The latter need to understand that, to the former, the value of information about another health system is not immediately clear. We saw this repeatedly throughout the project, and it is very succinctly expressed in this short film compilation of interviews.

7. The learning process must be owned by those who are able to act on it.

Much of the research into health policy transfusion to date has looked at the role international organisations have in spreading ideas, with very little looking at the role played by countries themselves. But their role in driving what information they consider useful about other countries is of crucial importance; to be acted on, it must answer the questions that keep them up at night. Put simply, national not international institutions need to be defining the questions, yet we know very little about how one country formulates questions about another.

8. Finally, different countries face different challenges when learning across health systems. Even within one country, the challenges change over time.

When trying to understand why learning across countries may not be happening, it is useful to consider three possibilities. Perhaps there actually isn’t a clear answer out there to the challenge they are up against – demand but little supply – (Nepal was arguably in this position when it started working out how community health workers could contribute to new born care). Perhaps the information exists (or could be obtained, but policy stakeholders have already made their decisions and don’t want to go back – supply but little demand – (Georgia may have been an example of this during its hospital privatisation reforms). Or maybe there is both supply and demand, but the mechanisms and resources (including internet, HR, and financing) available for bringing the two together are failing (could this currently be the case as Anglophone, Francophone and Lusophone countries try to learn from each-other?) Or is it some mix of all three?

The idea that countries should learn from each other is clearly appealing. But if it is actually to reap its benefits, we need to think more about how that learning process works beyond just the availability of information. Not learning from available information is a waste, but that does not mean it will happen.

Alex Jones is a health economist and was project manager of Learning for Action Across Health Systems. The project was commissioned by the Bill & Melinda Gates Foundation and implemented by Oxford Policy Management. Its objective was to investigate how external funding agencies can help countries learn from one another as they build and strengthen their health systems.