DIALHS
Policy Brief
15
Sept. 2016
The District Innovation, Action & Learning for Health Systems Development (DIALHS) project is a collaborative project of the Health Policy and S ystems & Health Economics Divisions of the UCT School of Public Health and Family Medicine, the School of Public Health at the University of the Western Cape, the City of Cape Town and the Western Cape Department of Health. For further information, contact Professor Uta Lehmann at [email protected] Knowledge co-­‐production through service-­‐research partnerships: Lessons from the Mitchells Plain sub-­‐district, South Africa Introduction Health systems and policy research (HPSR) is an applied field of research, centrally concerned with people, their relationships and the actions that they take towards strengthening health systems. This requires of researchers to engage with health systems actors, ranging from policymakers to service users, and be able to draw on their knowledge and experience in ways that are mutually generative and supportive, working in partnership with health systems actors and becoming familiar with the routine practices of the health system. Key messages •
HPSR strives to value and support the expertise, mindsets and experiences of all health systems players in strengthening health systems. Working in partnership between researchers and practitioners to generate knowledge, action and learning has a particularly important role in this endeavor. •
Knowledge co-­‐production in the field calls for using evidence beyond conventional data sources, treating data systematically generated in engagements and documentation of routine activities as valuable sources of learning. •
Working in partnership does not occur naturally. It requires substantial and continuous investments in time and trust from all ‘co-­‐producers’. This often is difficult in the pressurised environments service delivery. •
Researchers m ust remain aware of the need to work higher up the health system, to spread learning and leverage change outside the confines of specific projects. As the WHO Strategy on Health Policy and Systems Research asserts “While transforming the results of relevant research into policy and practice, HPSR also benefits by drawing on lessons generated from existing practices, which add to the knowledge obtained from designed research studies and also help generate fresh research questions, which need to be answered. Knowledge generation and knowledge translation are, therefore, not unidirectional in HPSR. They are bidirectional, with the decision-­‐makers, as well as the researchers, teaching each other and learning from one another” Since 2010 two academic institutions and two government health departments in Cape Town, South Africa have worked in a partnership to support the emerging district health system by working closely with m anagers and staff in one of the City’s sub-­‐
districts around governance issues. The project uses an action learning (AL) approach, which seeks to strengthen the interface between researchers a nd practitioners through a collective process of enquiry and sense-­‐making with cycles of planning, implementation, reflection and learning over a prolonged period of time, to support decision making. This research brief provides a brief overview of the approach to coproduction taken by the DIALHS project, outlining the novel methods used to support and learn about the district health system, and how it differs from more traditional types of research and engagement. It is one in a series of research and policy briefs that aim to share new insights about how action learning and co-­‐
production can enhance the resilience and responsiveness of health systems. What is knowledge co-­‐production? At the centre of co-­‐production lies a collective commitment to and ownership of processes of knowledge generation, which requires flexibility, responsiveness and trust among all partners. Key elements of the co-­‐production process in DIALHS have been: •
•
•
Creating spaces for conversation and joint reflection. Designing, supporting and reflecting on interventions to strengthen routine functions and processes in different parts of the health system. Collaborative presentations and writing for policy and academically oriented audiences. Questions such as ‘how do we understand what we are doing?’ (how do we make sense?), ‘how can we show w
hat we are doing?’ (what is our evidence?), and ‘how do we talk about what we are doing?’ (how d o we theorize?) have been central as we are working without the traditional research tools and scaffolding devices (pre-­‐determined questions, fixed p rotocols, pre-­‐determined schedules of data collection, analysis, and feedback). We found that much learning and knowledge production takes place in meetings, formal and informal, big and small, in cycles of conversations to plan and implement strands of work, reflect on their outcomes and re-­‐plan. Our evidence, therefore, includes not only “classic” formal data, such as interviews, which are recorded, transcribed and analysed, and observations recorded in field notes; but also notes from joint planning m eetings, workshops, conversations, report-­‐backs, which were shared between researchers and service partners, and a mix of detailed transcriptions and notes from the research team’s own planning and, more importantly, regular and systematic reflection (see Table 1). The data generated have to meetings meet the same criteria for validity and rigour as other forms of research: they have to be systematically collected, analysed and interpreted Through our data collection, documentation and reflection practices we are, thus, creating multiple and inter-­‐dependent cycles of increasingly rich data, analysis and learning. This policy brief is based on Uta 2
1
Lehmann and Lucy Gilson . Action learning for health system governance: the reward and challenge of co-­‐production. Health Policy Plan. 2015 Oct; 30(8): 957-­‐63. Composite reports of interventions (Community Profiling, programme support, facility manager support, key performance areas) As the project has taken very different approaches to research, action and learning we also had to rethink the nature of evidence that was generated. Table 1: Summary of DIALHS activities and data Activities and engagements which Data generated generated data Situational analysis •
Review of policy documents and minutes of statutory meetings •
Stakeholder interviews •
Observations of meetings Planning of interventions •
Community profiling and Local Area Groups •
Support for Presentations and Environmental Health meeting/workshop notes; Practitioners document reviews •
Support for primary health care facility managers •
HIV/AIDS & TB programme roles Implementation of Presentations, notes of interventions meetings, field notes and reports Review and reflection •
Notes of meetings with teams involved in intervention •
Presentations and reports to meetings of health service partners Research sub-­‐studies •
Interviews •
The transition process •
Observations from nurse to facility manager •
The information used by facility managers in routine decision-­‐making Meetings and reflections of •
Transcriptions and notes of research team reflective meetings of research team Interviews and reflective •
Notes of meetings with district conversations with sub-­‐district and managers district managers •
Notes of meetings with sub-­‐
district managers Cycles of The nature of evidence Co3producing*
ac'on*plans*
and*
implementa'
on*
!
Research!
sub3
studies!
Collabora've*
wri'ng*&*
presenta'ons*
!
Situa'onal!
assessment!
1
School of Public Health and Family Medicine, University of Cape Town; 2
School of Public Health, University of the Western Cape. The authors thank all collaborators of the DIAHLS project in Mitchells’ Plain. References are available on request. Collabora've*
engagement*
and*reflec'on*
!
Teaching!
programmes!
Na'onal!
and!int.!
repor'ng!
!
The DIALHS project is funded by The Atlantic Philanthropies (Grant No. 18269). DIAHLS is a RESYST-related
project. RESYST is funded by UKaid from the Department for International Develop-ment. However, the views expressed
do not necessarily reflect the department’s official policies.