SPECIAL SERIES ON THE DISTRICT HEALTH SYSTEM

 

Learning in the district health system: How can meetings become spaces of reflection?

 

 

O S Motshweneng^{I, II}; S Elloker^III; L Gilson^{IV, V}

^IFISQua; Department of Health and Wellness, Western Cape Government, Cape Town, South Africa
^IIFISQua; The Council for Health Service Accreditation of Southern Africa, Cape Town, South Africa
^IIIMA; Health Department, City of Cape Town Metropolitan Municipality, Cape Town, South Africa
^IVPhD; Division of Health Policy and Systems, School of Public Health, Faculty of Health Sciences, University of Cape Town, South Africa
^VPhD; Department of Global Health and Development, London School of Hygiene and Tropical Medicine, UK

Correspondence

 

 

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ABSTRACT

To fulfil its role, the District Health System (DHS) must enable and lead learning in the South African (SA) health system. Meetings are a core routine that can be leveraged to encourage learning in the DHS. In this article, we draw from existing experiences in SA to present practical steps that can be implemented to transform meetings into spaces of learning.

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The District Health System (DHS) is considered one of the key health system reforms in post-apartheid South Africa (SA). It is pivotal to both enabling the delivery of primary healthcare (PHC), including relevant patient referrals, and co-ordinating intersectoral action to address the social determinants of health.^[1,2] However, the DHS continues to face complex challenges that constrain its functioning -from inadequate delegations^[3,4] to command-and-control forms of leadership,^[4-6] authoritarian attitudes towards both patients and staff^[7] and resource constraints.^[3,6,8,9] Acute crises such as the recent COVID-19 pandemic and the current austerity measures compound the chronic challenges. As a result, 'new ways of being and doing' are required in the DHS.^[10] A key approach to encouraging new ways of being and doing, supporting the DHS to be responsive to changing community needs and wider contextual conditions, is to embed learning as a routine of the DHS.^[11] This includes strengthening the current DHS monitoring and evaluation system.^[12]

Making learning a system routine does not, moreover, necessarily require new resource investments or major structural changes. Instead, with some adaptations, existing processes can provide opportunities to encourage and embed learning. Meetings are one such process. At the DHS level, they regularly bring people with diverse perspectives together, sometimes around data but also, as illustrated in Fig. 1, for many other purposes - supporting service delivery, managing resources and engaging stakeholders. Therefore, meetings have the potential to support learning for different aims and with different consequences. As is needed in any learning health system (LHS),^[13] not only can meetings enable reflection on, and correction of, actions towards the achievement of stated goals or policy (single-loop learning), but they can also support changes at a policy level by being a space where underlying policies and goals are, themselves, questioned (double-loop learning).^[14] More fundamentally, meetings can contribute to improvements in how the system itself learns by providing opportunities to challenge and adapt existing learning structures and processes (triple-loop learning).^[14]

Despite their potential for encouraging learning, health system meetings in SA are usually a space of one-way information-sharing rather than two-way dialogue and engagement. They are often time-consuming, rigidly organised and, consequently, less productive. ^{[4,6,9,15,16]}

However, some existing experiences provide ideas about how to develop DHS meetings as learning spaces. This article draws on these, and our own, experiences, to present principles and practical steps that can be adopted to develop meetings as spaces of reflection and learning within the DHS. These practical steps are: (i) scan the environment for opportunities; (ii) develop the ground for meetings to become learning spaces; (iii) proactively plan for learning meetings; (iv) organise and manage the meeting to encourage learning; and (v) follow up to encourage learning beyond the meeting.

 

Leveraging meetings as spaces of learning

Step 1: Scan the environment for opportunities

As Fig. 1 demonstrates, there are currently multiple DHS-level meetings, organised differently and serving different purposes. The first step is to stand back and think about these meetings, what purpose they serve and how they are organised (a mapping exercise, as in Fig. 1, is a good start). Some are statutory requirements to complete specific tasks, and may be difficult to adapt. So, consider which meeting(s) provide the best potential spaces of learning -perhaps because they bring people together from across the system who, by sharing experience, can develop a fuller picture of district challenges and opportunities, or because the meeting is linked to long-term processes through which action can be supported. Regular planning and monitoring and evaluation cycles and quality management processes provide important opportunities for routine learning,^[13] as illustrated in Box 1, which describes an example of a district-level learning initiative linked to quality management. Having identified which meeting(s) provide the best potential spaces of learning, the next step is to develop the ground beneath, before adapting the actual processes around, and within, the meeting.

Step 2: Develop the ground for meetings to become spaces of learning

Bringing different groups of people together through meetings can result in a 'magic'al1' learning experience.^[17] However, the SA health system is historically hierarchical, and there are often tensions between groups of actors fragmented along professional and bureaucratic lines:

tween frontline workers and community representatives or managers and organised labour, for example. With such tensions, meetings between different groups can become hostile and easily descend into chaos. To ensure a productive meeting and an environment conducive to learning, investing in trusting relationships outside the meeting is critical. Practices of visible leadership such as a district manager visiting frontline workers,^[18] with emphasis on supportive supervision,^[19,20] can be instrumental in nurturing trust and enhancing learning.^[13] This need not be limited to formal relationships and reporting lines. Wider, informal coalitions with like-minded people can also be helpful in building trusting relationships to anchor and sustain change.^[21] Other important foundational principles on which to build trust and credibility include humility, responsiveness, listening, integrity and authenticity.^[22]

Furthermore, building and communicating a collective vision for learning is useful for shifting mindsets and ensuring that people come to the meeting expecting to engage and learn collectively. This was one of the success factors of the Monitoring and Response Units supporting quality improvement in Limpopo and Mpumalanga provinces, for example.^[21] Kruk et al.^[23] sum it up this way: 'Complex adaptive systems can thrive if actors within the system have a shared vision, clear rules, and space to allow evolution and learning.' Building and communicating a collective vision and mobilising people towards the achievement of that vision are the essence of leadership.^[24,25] Thus, developing the ground for meetings to become spaces of learning requires the exercise of leadership - which is considered to be one of the important enabling domains for LHS.^[13] More specifically, supportive and distributed leadership is instrumental in enabling learning, as shown in experiences from the Eastern Cape^[6] and the Western Cape provinces.^[18,26]

Step 3: Proactively plan for learning meetings

Having considered the ground beneath the meeting, the next step is to think about the processes around the meeting. For meetings to become spaces of learning, they need to be intentionally and proactively planned, with learning in mind. The name of the meeting, participants and preparation are important considerations.

Meeting name: Names act as precursors to meetings; they signal purpose and what is valued. Renaming a meeting creates a different sense of what it is about and helps set the tone and expectations for it. A 'monthly meeting' might be called the 'management and communications meeting',^[26] or a monitoring and evaluation meeting could be renamed a 'sense-making and reflection' meeting, for example. Sometimes it may be useful, where appropriate, to avoid the word 'meeting' altogether, as is the case with the Reflections on Quality (RoQ) sessions in Box 1. As part of the meeting naming or renaming process, staff may be asked what would add value for them - which also helps to promote a sense of ownership, and contributes to wider participation.

Meeting participants: It is equally important to think about who should be in the meeting because, as highlighted earlier, diversity can bring richness to the learning process. The inclusion of participants beyond the traditional boundaries of what is thought to be required is a key element of successful learning experiences in the SA DHS. This includes non-governmental organisation (NGO) partners in a government management meeting,^[18] primary care staff in a hospital meeting^'61 and production-level nurses and administrative clerks in a district-level management meeting (Box 1). Key is thinking about which voices to bring in to enable a rich learning experience, rather than being boxed in by professional and bureaucratic hierarchies. It may, then, be important to bring new groups of people into the meeting, to tap into their wisdom and experience and to work across the boundaries of system/community, services/support functions and healthcare/other sectors. Bringing different perspectives together aids problem diagnosis, and bringing those who need to work together to take action is also critical. This kind of collective problem-solving is another key feature of an LHS.^[13] However, participation needs to be carefully thought out. For example, bringing community representatives into a sensitive clinical space, such as a mortality and morbidity meeting, might not be constructive.

Meeting preparation: In terms of preparation, it is pivotal to ensure that participants have the right information, in the right format and at the right time. Ensuring that data are ready in time to be discussed, preparing them in formats that allow understanding and stimulate learning, and considering new sources of data important to understand current problems are all key actions to support the role of the meeting in learning. For example, additional data might throw light on patient satisfaction or on staff turnover, retention and satisfaction. Those responsible for data analysis and reporting may need a confidence boost to work slightly differently, or support to communicate differently. It is always useful, wherever possible, to share data with participants before the meeting to enable better preparation. Relevant data are not limited to statistics; other forms of data - both formal and informal,^[18,21] especially from the ground, should also be available.

Step 4: Organise and manage the meeting to encourage learning

Moving from the processes around the meeting, we now consider the processes and practices within the meeting. Therefore the next step is to think carefully about how to organise and manage the meeting. Table 1 outlines some key principles, processes and practices that can be considered. A critical point is to spread power and engagement - the meeting convenor does not need to have all the answers or do all the talking. Learning requires that all those present are acknowledged as having contributions to make and to engage. Rotating meeting chairing, engaging various people in leading conversations, encouraging paired thinking and small-group work are some important practices to consider. Facilitation and enablement, rather than instruction and command, are critical styles to encourage participation across the room, and enable learning. There are more pragmatic considerations as well, of which time management is chief. A focused agenda with time allocated to each item can help with managing time. For some meetings it might be useful not to have an agenda at all, but to open the space for reflection and allow participants to lead conversations based on a predetermined topic, or a hybrid of less structured reflection followed by a more structured agenda-based discussion. But such meetings need to be managed carefully, and strong facilitation skills are important to ensure meaningful engagement and strict time management.

To aid time management, meeting time should preferably not be used for information sharing. Instead, other means - such as an email - should be used. If there is a strong need to share information, this should be timebound and ideally at the end of the meeting. Lastly, remember to conclude the meeting on time, as this signals respect and will motivate participants to attend the next meeting.

Step 5: Follow-up to encourage learning beyond the meeting

Learning should continue after the meeting, and the last step is to think about how to link the discussions and outcomes from the meeting with processes outside the meeting. Firstly, it is important to ensure that participants leave the meeting having a clear understanding of the next steps: what to think about, what actions to experiment with -and asking for their views on these issues is useful. Secondly, identify opportunities for follow-up within other routine processes rather than waiting for the next meeting. Be curious and creative - search for linkages and connections across the system. Look around at what is happening, ask what is important and meaningful for people and link to those processes. Relevant examples include supervision or mentorship visits, informal check-ins, planning and monitoring and evaluation activities. However, be cautious to avoid the compliance mode of follow-up. The goal is not to determine whether people have completed tasks but to identify opportunities for further support. Therefore, instead of asking 'Did you do this?' rather ask 'How is it going with that?' or 'Do you think the discussion from our previous meeting could be relevant here?', for example. Post-meeting discussions are, also, an important opportunity to acknowledge contributions and boost the confidence of role-players. Lastly, as part of follow-up, look for opportunities for cascading change down and across the system -from district to facility level - so that learning becomes entrenched, and guard against risks of regressing to the 'old way of doing things', which is often a challenge in health system change.

 

Conclusion

The DHS is a critical organisational layer in the SA health system. But to fulfil its roles in supporting PHC and enabling intersectoral action for health, the DHS must enable and lead learning. Meetings are an important leverage point that can be adapted to encourage learning, without requiring additional resources. In this article, we have presented practical steps that can be used to transform meetings into learning spaces. These principles and practices are simple ideas about how to shift meetings away from being spaces of one-way information sharing (single-loop learning), to being spaces of two-way dialogue and engagement (double-loop learning) and more - to being spaces that themselves adapt over time to support the creativity and innovation needed to improve (triple-loop learning). These practices do not offer a one-size-fits-all approach and do not all need to be implemented in one meeting; different types of meetings will require different sets of actions. Yet it is always important to ensure congruency between what you do before the meeting, during the meeting and after the meeting, as actions in one stage can support or undermine efforts in other stages. Finally, change takes time - so intentionality, consistency and patience are key.

Declaration. None.

Acknowledgements. We would like to thank the following colleagues for reviewing the article and providing valuable comments: Associate Prof. Beth Engelbrecht, Prof. Helen Schneider and Dr Nonhlanhla Nxumalo.

Author contributions. LG conceptualised the article, following which all authors contributed significantly to its development. OSM wrote the first draft manuscript, which was then reviewed by all authors. All authors approved the final manuscript.

Funding. None.

Conflicts of interest. None.

 

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Correspondence:
O S Motshweneng
oupamotshweneng@gmail.com

Accepted 8 April 2024