Background

Since the early 2000s, there has been growing recognition of the importance of governance to health system performance in low- and middle-income countries (LMICs). Early work provided important conceptual lenses for how to think about governance [1] as well as assessment frameworks [2]. Subsequent empirical work emphasised the critical role of governance in sustaining well-performing health systems [3], and a more recent analysis piece concludes that “Governance is central to improving health sector performance and achieving Universal Health Coverage” ([4], p. 1).

However, it is less clear how to strengthen health system governance and researching governance issues is far from straightforward. Indeed, in 2008, the Alliance for Health Policy and Systems Research (AHPSR) argued that ‘governance and accountability’ was a neglected research issue as a result of conceptual and design challenges as well as the political sensitivity of such research [5]. The AHPSR made three methodological recommendations for governance research, namely (1) use qualitative approaches, such as participatory approaches, participant observation, historical cases and processes, and institutional analysis; (2) implement multi-country field research programmes to share analytic approaches, address shared questions and share experience of addressing the practical challenges of such research; and (3) undertake such research with engagement from, and addressing specific questions identified with, policy-makers and managers.

Following on from the third recommendation, the AHPSR also argued that “work on governance and accountability has the potential to gather the actors that contribute to health systems to not only generate new knowledge, but also to generate the dialogue, self-reflection and analysis that more directly uses this knowledge for policy change and offsets policy opposition” ([5], p. 10). It would later call this type of work ‘embedded research’ [6], which in higher-income country discussions is also called ‘co-production research’ [7]. As others have also noted, because governance strategies are context specific, as they are “rolled out, they should be linked to careful research that both enables learning as to what works, and facilitates fine-tuning and adaption of the strategy” ([4], p. 4).

Against this background, the Resilient and Responsive Health System (RESYST) consortium proposed and implemented a 7-year programme of research (2012–18 https://resyst.lshtm.ac.uk/) that included a particular focus on governance and leadership. Reflecting the AHPSR recommendations above, this programme of qualitative governance research was implemented through iterative cycles of research and reflection undertaken collaboratively with health managers in three ‘learning sites’. One was located in Kenya and supported by researchers at the Kenyan Medical Research Institute–Wellcome Trust Programme (KWTRP) and two were located in South Africa, one supported by researchers at the Centre for Health Policy, University of Witwatersrand, and the other by a collaborative team from the School of Public Health and Family Medicine, University of Cape Town, and the School of Public Health, University of the Western Cape.

Our work was founded on the understanding that governance is a “dynamic and complex process, rather than a normative health system goal achieved through the architecture and design of accountability and regulatory frameworks” ([8], p. 1–2), [9]. Our research and intervention work, as detailed in Box 1, specifically investigated the micro-practices of governance, that is, managers’ and health workers’ everyday practices of decision-making. In addition, as discussed further below, we have engaged in policy and management discussions at higher levels of the health system in both countries, supported cross-country engagement and learning, and reached a wider audience through using the research in teaching programmes, publications and presentations at international conferences.

Learning site activities

Where and with whom did we work?

The learning sites are all located within health districts, as nationally defined, with work conducted at district and sub-district levels across sites as well as in primary health care (PHC) facilities and, in Kenya, district hospitals. These sites are Kilifi County, Kenya (formerly Kilifi District); Mitchell’s Plain, Cape Town, Western Cape province, South Africa (with work in the wider Area South, Cape Town, in 2017–2018); and Sedibeng District, Gauteng province, South Africa. There are differences in the geographic and socioeconomic context of each site [28] (and online supplementary material, https://doi.org/10.1136/bmjgh-2016-000224). Kilifi is a relatively poor rural area in Kenya, whereas the South Africa sites are located in urban areas and are relatively well-off compared to national averages (although Mitchell’s Plain sub-district is relatively poor within the wider City of Cape Town). From a health system perspective, meanwhile, PHC utilisation levels were similar across sites and PHC performance, as judged by antenatal care utilisation levels, was reasonable but showed room for improvement everywhere.

These areas were selected as learning sites based on the prior history of engagement between the research teams and local health managers as well as on their geographic proximity to the researchers’ organisational locations (Box 2). By providing a platform of trusting relationships and enabling the frequent presence of researchers in the sites, these features allowed the learning site work to be initiated and sustained over time. Critically, they enabled the research teams to implement their activities in a flexible manner, responding to opportunities and challenges that arose over time as well as managerial views, supporting, in turn, the deepening of our relationships. The research teams were multi-disciplinary, comprising people with different social science backgrounds and varying depths of health policy and systems research (HPSR) experience as well as health professionals. Although, across sites, there was some turnover over time in both the research and managerial teams, the continuity of key researchers and managers within a sustained platform of relationships provided the base from which to draw in new team members.

What did we do?

Table 1 provides details about how our core activities were implemented collaboratively over time with local health managers in each site. There were some differences between sites in our initial approach to the research and in the balance between more traditional, protocol-driven research activities and a more flexible, action learning process. Nonetheless, our activities [33] were commonly founded on principles of action learning and co-production drawn from outside the health sector and outside health policy and systems research [34,35,36,37].

Table 1 Core learning site activities
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The table highlights six common features of our activities.

  1. 1.

    Multiple research and intervention activities were implemented over time in each site:

    • The research comprised specific qualitative research projects as well as longitudinal processes of observation and inquiry. The interventions, several of which focused on leadership development [31], were either led by learning site managers or by external facilitators in agreement with these managers, rather than being externally driven.

  2. 2.

    Collective leadership by the research team and local managers for the iterative development of all activities:

    • Each new activity was identified collectively through cycles of research, reflection and reporting, and was then supported by the team of researchers and health managers. Over time, previous rounds of research then provided the platform for newer research, supporting deeper inquiry into specific issues/experiences and allowing some external events (such as devolution in Kenya) to be tracked over time. In addition, home-grown interventions evolved out of the research and were tracked as implemented.

  3. 3.

    Reflective practice was the core feature of all learning site activities, supporting sense-making and learning:

    • Researchers met together to reflect on observations and emerging insights, and reflective meetings between researchers and managers allowed emerging insights to be tested to deepen understanding. It was also common practice to deepen reflection by bringing theoretical and conceptual frameworks and questions as well as experience from the other sites into the conversations between researchers and managers.

  4. 4.

    Multiple data sets were generated in each site:

    • Formal data collection processes around specific research questions were complemented by data generated through regular observation and participation in learning site life and from reflective discussions [33].

  5. 5.

    Co-production of knowledge and action was the hallmark of our work:

    • This was implemented through collective leadership and reflective practice. It is also demonstrated in the co-authorship of formal papers, in the implementation of new managerial activities across sites and in the development of policy lessons.

  6. 6.

    Paying careful attention to our research approach and related ethics issues:

    • Initially, we outlined and discussed the core features of our work in our institutional and national ethics review proposals. Subsequently, we regularly reflected on the overall approach [38] and the ethical issues and dilemmas we encountered as it evolved (Scott V, Xapile Z: Negotiating ethics at the frontline of HPSR practice: participatory action research with health managers, unpublished), [39]. We also established an additional informal annual science/ethics review group to provide us with an independent review of our evolving learning site ideas and activities, including the need to submit amendments or changes to the formal ethics’ review panels.

How did we work?

Around the core activities, as shown in Fig. 1, an additional set of engagements within and outside the learning sites were important both in sustaining relationships and in sharing the learnings from the primary research and intervention work in each site more widely. These activities were developed in response to site-, organisation- and country-specific opportunities and so inevitably varied, as described in Table 2. However, they all sought to strengthen the researcher–manager relationships underpinning learning site activities, including by allowing better understanding of each other’s organisational worlds. For example, researchers’ engagement in managerial activities brought wider insights into the demands of health management. Meanwhile, managers’ involvement in conferences and teaching provided insights into wider academic debates and practice. The activities outlined in Table 2 also allowed the research learnings to be shared more widely at national and global levels. Wherever possible within national settings, efforts were made to use the learning site work to inform wider policy and practice discussions. As the table notes, in some instances, these efforts were linked to specific formal policy processes. In other instances, more informal engagements allowed researchers, as in Kenya, to offer strategic advice on various issues or, as in Mitchell’s Plain, informed broader conceptual thinking of relevance to policy discussions. In Sedibeng, engaging at higher system levels appeared to be more challenging than elsewhere, perhaps because instability within the district governance structures focussed the managers and researchers on supporting this district’s own development. However, across all sites, research findings were also used within formal teaching programmes, allowing learning site experience to be disseminated more widely to audiences of public sector managers as well as to future health policy and systems researchers. Finally, at the global level, the learning site approach and experiences were shared through collective RESYST engagement at the 2016 and 2018 Global Health Systems Research symposia, and through peer-reviewed journal papers.

Fig. 1
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The package of learning site activities

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Table 2 Activities to extend and deepen learnings
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What are the achievements and challenges of the learning site approach?

Achievements

Across all three learning sites, researchers and health managers involved in this work agree that the approach has generated value for understanding health system governance and for strengthening it.

In annual reporting to the Department for International Development, United Kingdom – the RESYST funder – the learning sites reported policy impact at both instrumental and conceptual levels [41] across countries. As Box 3 summarises, there were several instances of policy development and practice change resulting from learning site work (Box 4), with the latter also observed by the research teams. Moreover, as already discussed (Table 2), the links to the research partners’ teaching activities as well as our collective publications and participation in global conferences have enabled us to share our experience more widely. These activities support a multiplier effect in terms of audience size; additionally, teaching, in particular, allows a deeper engagement with the learning site experiences.

As illuminated in Box 4, learning site managers have found particular value in the reflective practice principles and practices to which they have been introduced, and that have allowed them to stand back from the persistent challenges they face and think again about how to address them [42]. Across sites, the managers’ growing understanding of the health system, in particular, as comprising both software and hardware [12] has also brought them valuable insights into the system in which they work and how to lead change within it. They judge that these practices and ideas have supported them to adopt a more proactive and confident approach to management and has generated the positive energy required to tackle problems. They have valued the safe spaces that have been created through reflective practice, allowing difficult conversations and bringing together different actors in the system to work together [29]. They have appreciated the training and mentorship that they have received in leadership and communication practices, for example, developing new skills they now regard as essential for their management positions. They judge that these interventions were well tailored to their needs precisely because they emerged from prior rounds of learning site research and understanding (Nzinga J, Boga M, Kagwanja N, Waithaka D, Barasa E, Tsofa B, Gilson L, Molyneux S: Strengthening health system governance: the potential of innovative leadership development in supporting health managers’ leadership capacities, unpublished), [31]. In some instances, researchers have also been valued as an external resource on which managers can draw to offer advice about tackling problems (Table 2). Finally, the managers judge that the critical factor underpinning these valued outcomes has been the “how of the learning site approach”. The key features of the approach that they have identified are the efforts to address, and respond to, managerial needs and experiences; continued engagement over time and regular feedback focussed on “how can we learn from this and not on this was done wrong”; and a process in which managers were not just participants but also co-producers of knowledge and action, “appreciated for the work we do”. The development of strong relationships between managers and researchers was seen as central to the approach and its value, based on mutual respect and a growing understanding of each other’s contexts.

These relationships are also important to the researchers and the value they have derived from the learning site approach. For them, the value lies in:

  • better understanding of the complexity of health systems and, in particular, emergence as an element of complexity [27, 43] as well as of the micro-practices of governance (Box 1). This was generated through observing change as it unfolds over many years, gaining insight into the experience and tacit knowledge managers use in daily decision-making and developing a more nuanced understanding of the contextual factors influencing this decision-making;

  • the deeper insights generated when trusting relationships provide spaces for reflection and openness even on sensitive issues and experiences;

  • being able to generate layers of understanding and knowledge; this was enabled through cycles of engagement over time involving observation, interviews, shared experiences and collective reflection and these, in turn, underpin the trustworthiness of the insights developed [33];

  • opening up pathways to influencing practice and opportunities for wider policy influence through research uptake; this resulted from working hand-in-hand with managers and supporting them to take action to strengthen local governance processes as well as from sharing the experiences upwards and outward into formal policy processes, wider reporting and teaching activities;

  • the opportunities provided through the platform of work to enable capacity strengthening – mutual learning – around health system governance and this form of embedded HPSR, for researchers at all levels of experience (including opportunities for master’s, doctoral and postdoctoral research);

  • opportunities to generate new research questions and focal areas that are derived from past insights, so deepening and sharpening inquiry. For example, building on our understanding of everyday resilience [28], we have undertaken further work to test and develop our insights [32];

  • opportunities to generate learning from comparisons across settings – given a common focus and approach in the learning sites. We have also demonstrated both the many common challenges district health systems face in different settings, and that there is much to learn across settings about how to respond to those challenges;

  • opportunities to deepen and refine the overall learning site approach as an approach to embedded research – by sharing experience across the three sites, and among researchers and managers. We have, for example, learnt from each other about the importance of engaging managers at higher levels of the health system or about drawing learning site experience into teaching activities, to support wider impacts;

  • deeper awareness of the ways in which the science and the ethics of this work is inter-twined, and of the need to ensure constant reflection on interactions and their implications in maintaining ethical practice. As researchers, we need to ensure transparency and respect in our engagements with our managerial colleagues, and to support longer-term learning in ways that minimise negative repercussions for individuals and organisations in terms of relationships and reputations.

Challenges

There are, of course, also challenges and limits to the learning site work. We highlight particular areas of critique here, linking our own experiences to a recent paper on co-production [7].

In an early evaluation of the overall RESYST programme of work, the learning site activities were criticised for implementing a programme of primarily descriptive and observational research that might neither produce generalisable lessons of “verifiable policy relevance” nor contribute to new knowledge. As Oliver et al. ([7], p. 5) note, a co-production researcher risks being seen as “an academic lightweight, producing nothing of substance”, “being asked to answer questions which are dull, not novel (little contribution to the scientific literature), or not generalizable (focused on local issues)”.

We recognise that we have not developed a traditional intervention ‘model’ for health system strengthening in other settings. Our modelling lies, rather, in our processes of learning, engagement, and intervention learning and, through them, we judge that we have made conceptual and instrumental [41] contributions to health system governance and strengthening health systems. The ‘thick description’ of the micro-practices of governance and everyday realities of health system managers and staff has added to the limited empirical knowledge base of health governance contexts and practices in LMICs (Box 1), with insights of relevance beyond the learning sites. It has also provided the platform for developing interventions rooted in those realities, rather than imposed on them from outside (be that from national level or by external actors). We have, then, developed leadership development interventions in these sites based on our initial research (Nzinga J, Boga M, Kagwanja N, Waithaka D, Barasa E, Tsofa B, Gilson L, Molyneux S: Strengthening health system governance: the potential of innovative leadership development in supporting health managers’ leadership capacities, unpublished), [31], that could be considered in other settings, and we have fed our research insights into our own and others’ leadership development activities. In addition, the co-production of these health system understandings itself supported learning site managers to adapt their own practices and to develop home-grown governance interventions. In complex adaptive systems such changes are seen as key steps in the process of adaptive learning important in nurturing emergent and sustained change [44, 45]. Finally, as previously noted, our research has evolved over time to allow initial insights about everyday resilience to be further tested and developed – a process of research we judge as simply necessary in investigating the contextually specific phenomena that represent the essence of governance in complex health systems. We look forward to publishing our revised learnings [32].

There are, nonetheless, professional and personal risks from this type of work [7]. It has not always been possible to work consistently and effectively with managers at higher levels of the health system to translate learnings into wider system gain. Tracking conceptual and instrumental impacts is not straightforward. The breadth of activities we have implemented (Fig. 1) goes well beyond formal research or teaching activities and not all are well valued by academic or research organisations. The activities have also been demanding because they have, purposefully, been implemented over a fairly lengthy period of time and connected to wider organisational activities, such as teaching, to support wider impacts. Finally, there has been personnel turnover in the research teams, and some managerial instability, particularly in Sedibeng, which has sometimes constrained our work. Although likely inevitable in any long-term research endeavour, managing relationships and research over time is part of the “emotional labour of working collaboratively” ([7], p. 5).

Yet, the longitudinal dimension of our work has allowed us to deepen our insights about the complexity of health systems and their governance, and how they change over time. Being embedded in a health system also assists in tracking how ideas and new ways of thinking feed into policy development or influence wider action, as managers use their positional power (see Boxes 3 and 4). Our fairly long-term funding has clearly been important to sustaining this work.

A further critique of coproduction research processes is that “researchers risk being seen as partisan and/or lacking in credibility” ([7], p. 5) where they are used to add legitimacy to pre-existing political positions or where they only report what is judged acceptable to policy/management partners. We recognise these issues as critical ethical issues and see them as a concern for all HPSR work, given its applied focus, rather than only for co-production research [46]. We have tried to pay active attention to managing the many sets of power relationships within our collaborations as part of our ethical and reflective practice. Perhaps we have been fortunate in rarely confronting situations of interpersonal conflict or disagreement between researchers and managers in any site. However, we have certainly discussed how and to whom to report some of our insights – less to avoid conflict, and more to encourage understanding and action. Yet, certainly, a risk of this form of research is in it being seen as biased and not independent – in part, itself a reflection of the enduring epistemological battles amongst health researchers [7, 47].

A final critique of our approach is that we did not purposefully evaluate whether and how we have had system impacts, and at what cost. We simply did not initially see our work as a system intervention. However, we do now recognise the potential value of addressing these criticisms in any future learning site work to allow deeper understanding of the overall approach. Careful attention would need to be paid to delineating and tracking the full set of relevant activities which, as summarised in Fig. 1, change over time; additionally, tracking the full range of possible impacts from these activities would have challenges. Simply resourcing an additional layer of such evaluation could also be difficult. Nonetheless, there would be value in testing and building the case for the potential of learning sites as an HPSR methodology for system impact.

Conclusions

Whilst recognising the challenges identified, we suggest that our experience shows that this sort of long-term, embedded/co-production approach offers value for understanding health system governance, and addresses the AHPSR [5] recommendations for governance research. However, we do not suggest that our approach is the only way of doing such research.

Overall, we propose five key lessons from the experiences we have presented.

  1. 1.

    Through the learning sites we have been able better to understand the micro-practices of governance and the complex everyday realities of health systems in two countries. In line with wider work on bottom-up perspectives of policy change [48] and development thinking [44], we judge that these realities are vital to consider in developing system strengthening interventions that either work with the grain of existing institutional arrangements or, appropriately and knowingly, challenge those arrangements.

  2. 2.

    Through our work, we have seen the potential to change routine managerial practice by offering opportunities for sensemaking through a process of action learning and reflection. Managers lead change in their systems and welcome the opportunity to engage with ideas, such as the software of health systems, everyday resilience or complex health systems, that allow them to make sense of their world and how to act differently within it. Such emergent change is more widely seen as an essential element of transformative organisational change [27]; these insights also have particular value for how to think about, and do, leadership development in LMIC settings [31, 49].

  3. 3.

    Doing this sort of work, and seeking wider impact, requires entrepreneurial behaviour, supportive organisational environments and, at least some, long-term research funding. It cannot be seen purely as a researcher-driven endeavour and, for impact, must be linked to sustained engagements with higher level managers across the health system as well as to activities such as teaching, and various collective activities. It is not a project activity, but a longer-term programme of work, and there are professional and personal risks to it.

  4. 4.

    Initiating such activities is enabled by an existing platform of trusting relationships between researchers and managers, whilst sustaining them over time requires that continued attention is paid to maintaining those relationships. Relationships among researchers are also important. Trust and openness are critical. Being responsive to each other and being flexible, whilst also being able to set boundaries and navigate them, are necessary.

  5. 5.

    We found real value in working in multiple sites as the cross-site engagement deepened learning for managers and researchers – allowing comparison of different contexts and experiences, with recognition of the commonalities in experience. Whilst the micro-practices of governance are inevitably context specific, there are shared patterns and themes in these experiences across settings that provide the basis for new managerial practices and new ways of thinking about how to support them [25, 28].

We welcome further engagement with our experiences and reflections.