Collective sensemaking for action: researchers and decision makers working collaboratively to strengthen health systems

Co-production principles and practice

Despite differences in country context and health system setting, two key principles of engagement and a core set of collaboration practices are common to all initiatives (box 2).711The first principle is that power is shared between researchers and decision makers by valuing and actively drawing on their different perspectives and experience. For example, understanding that solutions to challenges lie within the health system, researchers working within the Kenyan clinical information network facilitate practitioner problem solving for hospital paediatric care. The process encourages peer learning and peer accountability around the use of hospital data to inform paediatric care decision making.131415

In the Kilifi county and Sedibeng district health system learning sites, joint reflective engagements between researchers and managers deepen shared understanding of governance and leadership experiences.16 Managers bring their lived experiences of working with constant policy reform and resource constraints to these engagements, and researchers bring systematically collected insights and understanding of relevant academic literature. Similarly, within the Western Cape provincial emergency medicine service in South Africa the embedded researcher has drawn on arts based approaches to support reflection among managers about organisational processes, the lived experience of frontline staff, and emergency medicine service and community linkages.18 Finally, within the Western Cape HPSR Journal Club research papers stimulate collective thinking among managers and researchers about health system complexity and how to work with it.17 The researchers purposively initiated these engagements by inviting partnership from decision makers, and have then, in some cases, continued to steer or coordinate activities by agreement with their partners.

The second principle builds on the first and is that trusting relationships are developed and sustained. In the five initiatives discussed here, trust was founded on years of prior organisational collaboration and on sustained personal relationships. Trust was also nurtured by having, or negotiating, shared goals of co-production. Examples include improving paediatric care in the clinical information network, strengthening the health system towards equity in the journal club, and enabling distributed leadership in the Western Cape emergency medicine service.

Showing respect and courtesy sustains these relationships and also helps to navigate power dynamics among the partners. Purposeful and active listening are important practices, together with generosity and acknowledgement of the other’s experience. For example, in the HPSR Journal Club, sharing facilitation, reviewing, and commentary roles among researchers and decision makers acknowledges the experience of everyone present and, together with using first names rather than professional titles, flattens hierarchies. Constant, regular feedback about the clinical information network to decision makers at various system levels has itself shown respect and courtesy for them. Moreover, wider engagements across initiatives have provided opportunities to show commitment to each other, enhancing trust. The KEMRI-Wellcome Trust Research Programme has, for example, supported the country covid-19 response in 2020 by offering testing services, knowledge synthesis, antibody surveillance, as well as clinical surveillance leveraging on the clinical information network. In other settings, researchers have provided strategic and management advice, while practitioners have supported postgraduate teaching programmes. Together these engagements represent webs of joint learning that spread the benefits of co-production.

Those involved in these initiatives value these principles and practices because they allow mutual and deep learning, feeding into their wider work. Health system decision makers appreciate the opportunity to reflect with researchers, hear different perspectives, generate new understandings about their health system environments, and, ultimately, make decisions and act differently. For example, in the Kilifi learning site reflective practice sessions have provided a safe space for managers to think together about how to tackle the direct, and disruptive, involvement of local political actors in service delivery decision making. Working with existing guidelines and applying newly learnt communication skills, managers reported a reduction in disruptive engagements.16 At the same time, the initiatives have given researchers unusual opportunities for close engagement with health system decision makers and their everyday realities. The insights generated from the learning site engagements have, for example, contributed to formal knowledge production around the micro-practices of governance and everyday health system resilience,1920 and created opportunities to develop context specific leadership development interventions.17 Across initiatives, the insights have also fed into researchers’ policy advisory roles as well as new, collaboratively developed research projects.

Benefits of co-production

Each co-production experience indicates the ways in which knowing and doing, research and practice, are intertwined. They also show how co-production processes connected to wider webs of learning generate tangible consequences for the health system in which they are located. In South Africa, the shared understandings generated through the HPSR Journal Club have informed provincial policy documents, such as those focused on strengthening health system resilience and leadership development, and influenced senior managers’ own leadership practices.17 Researchers have also translated local level learning from the Kilifi learning site into wider sub-national and national level policy advice. The clinical information network has supported the revision, adaptation, and uptake of evidence based Ministry of Health paediatric protocols, contributing to improved hospital paediatric care nationally.14

In the South African emergency medical service experience, the embedded researcher has supported organisational conversations about the forms of leadership needed to problem solve around complex issues, such as delivering emergency care safely within community settings characterised by social instability and violence. Workplace leadership development activities have also been an important avenue of decision maker engagement and wider impact in the Kilifi learning site. Through such activities the clinical information network has also supported the emergence of frontline service delivery leaders, who have realised workplace changes with researcher support.

The insights developed through co-production have also been fed back into the researchers’ postgraduate training programmes. Ideas, cases studies, documentary films, and decision maker as educators have been brought into the classroom to stimulate learning by the next generation of health system leaders and researchers.

Finally, the experiences show how health system researchers can become embedded in the ecosystem of decision makers,11 continuing to engage over time. This relationship represents a form of social capital that can support responses to new situations. For example, the emergency medical services embedded researcher collaborated with a group of community organisers and social activists to catalyse Cape Town Together, a self-organising, neighbourhood level community network responding to local challenges arising from covid-19.21 Taking on the practices of co-production, the network draws on its collective energy and wisdom to respond to community needs.

Challenges of co-production

In our experience, long term collaborative engagements have to survive turnover among the decision makers and researchers concerned and constant attention is needed to sustain trusting relationships. The evolving nature of collaboration also brings its own demands. In the clinical information network, for example, researchers have faced multiple requests to take responsibility for new activities, such as expanding to other specialties and more hospitals. They have responded by reminding network members about initially agreed roles and responsibilities, and have supported members to build their own capacity to take responsibility for extending activities.

The boundary spanning work of co-production can have personal and professional costs for all those concerned. It is emotionally taxing to renegotiate relationships over time in response to changing personnel and changes in context, and to sustain trust.22 The time demands of engagement may be seen as a burden for busy people, especially when relationship building is not considered a priority or they see limited value from it. Such activities are also not well recognised in the career development pathways of researchers or health system managers.

In the research world, the context rich insights gained through co-production have been criticised as having limited generalisability,16 while embedded research is seen to threaten neutrality and independence.22 The risk of becoming aligned to certain actors or perspectives within what can be politically charged and socially unequal contexts is also an ethical dilemma for researchers. Constant trust building through regular feedback and update meetings with key health system actors and ethical oversight approaches appropriate to health policy and systems research are important.23

Co-production initiatives must also confront the challenge of insecure resourcing. In the Kilifi learning site, new research proposals have been developed to sustain activities over time. In other initiatives, the co-production process has been institutionalised within health service practice. For example, in South Africa, health system managers allocate a few hours every two months to participate in the HPSR Journal Club, while the position of emergency medicine service embedded researcher was secured as a part time government post.

Finally, broader health system factors also affect these types of collaborative arrangements. For example, the clinical information network seeks to improve paediatric outcomes through better use of relevant data. However, achievement of these improved outcomes has been limited by inadequate medical supplies and equipment, insufficient human resources, and poor quality information systems. Managing the power dynamics within the health system can also be challenging. As experienced in Kilifi, health system decision makers working at different system levels do not always understand each other’s professional constraints. This has generated tension and impacted on collective problem solving. Disagreements about roles among higher level managers prevented the extension of the Sedibeng leadership development intervention to a wider group of managers.