The Community of Practice Health Service Delivery: Strengthening Health District Teams to Accelerate PHC Improvement in Africa
By Jean Paul Dossou, Basile Keugoung, Elisabeth Tadiri, and Hannah Ratcliffe
A Community of Practice (CoP) is a group of people who interact regularly to produce and share knowledge and implementation practices and effectively create linkages between “knowledge holders.” A CoP possesses three critical dimensions: mutual engagement, joint enterprise, and a shared repertoire. While CoPs have been used as a strategy for knowledge management in the business sector for decades, in recent years they have been increasingly employed as a method for improving global health. The Community of Practice Health Service Delivery (CoP HSD) is one of eight CoPs within Harmonization for Health in Africa (HHA), a collaborative initiative for health systems strengthening. CoP HSD launched in 2009 as a virtual community to focus on strengthening health systems at the district level through better information and knowledge sharing. To date, CoP HSD has more than 1,400 active members from 78 countries. The CoP HSD is supported by UNICEF and other partners such as the Belgian Development Cooperation and the Institute of Tropical Medicine at Antwerp-Belgium.
The CoP HSD: Scope and key tools
The CoP HSD was developed as a solution to address the identified gap in information availability at the front-line service delivery level. Despite the changing landscape of new information and communication technologies in sub-Saharan African health systems, peripheral levels of the system are often still left behind without access to the most current health information. The CoP HSD vision is to fill this gap by accelerating knowledge sharing across all levels of the health system. CoP HSD aims to reduce the reliance on only central levels, vertical programs and pharmaceutical companies as the sole sources of information, and improve access to guidelines and scientific information. The use of technology is critical to the CoP HSD, as online tools are a cost-effective way to share best practices, new knowledge, and implementation experiences. However face-to-face events are key and are used as complementary knowledge sharing tools by the CoP HSD.
The CoP HSD has created a clear identity and used multiple active and passive recruiting methods to help grow the volume of the community to its current 1,400 members. The CoP HSD operates through several key methods to translate knowledge into action. These methods include: i) maintaining an online discussion forum and blog; ii) publishing a regular newsletter; iii) increasing identity awareness and informing the population through social media with a Facebook page with more than 10,000 likes (as of June 2016); iv) holding face-to-face events (for example, the Cotonou workshop on health information systems); and v) conducting research on user-defined priorities, as illustrated by the project “Mobilization 2.0 of health district management teams to fight against outbreaks and other emerging health issues” (Mobilisation2.0).
Key focus: Empowering local actors to use data for action
The CoP HSD aims to build a network of district health management teams throughout sub-Saharan Africa. The CoP HSD chose to focus on the district level because this is where critical primary health care services are delivered and local plans and priorities should be set. However, the CoP HSD facilitators believe that simply expanding access to information and data at the district level may not in many circumstances be enough to result in change. Therefore, we have made an explicit commitment to empower local, grassroots provider voices to create a new type of working environment that values information sharing and learning within and across countries and health systems. A core principle of the CoP HSD is then to be a horizontal, action-oriented learning network in which the experiences and opinions of a peripheral-level nurse are valued as highly and heard as loudly as the voice of a minister of health.
This idea of creating a horizontal learning environment is a key differentiation between CoPs and other knowledge management strategies, and enables the sharing of both explicit and tacit knowledge and the fostering of mutual trust. In addition, the process of bottom-up agenda setting is an important aspect of the CoP HSD, which ensures that members themselves define the priority questions, test innovative solutions, and share results. Above all, the CoP HSD works toward a “collective intelligence,” a term which encompasses these core beliefs of horizontal learning and knowledge sharing for the following key purposes: i) improve a collective understanding of key health system challenges; ii) reach a better alignment on collective objectives; iii) improve collective decision-making; and iv) provide more opportunities for collective actions. As such the “collective intelligence” concept is a key mechanism, in the theory of action of the CoP HSD, to reach an optimal mobilization of all the competencies available, to raise up and empower actors at all levels of health service delivery to make decisions and take action for sustainable changes and progress in PHC improvement.
The Mobilisation 2.0 project: testing the strategy in action
An example of this process in action can be seen in the “Mobilization 2.0” project, which is going on in two test countries: Benin and Guinea. In this project, the CoP HSD implements fast learning cycles, using online survey tools to collect information from members about the organization and management of District Health Management Teams (HDMT) in their locality. The CoP HSD then rapidly analyzes and benchmarks the collected data and produces data visualizations, which are shared with all who participated in the survey. Survey participants are able to use this information to identify challenges or interesting examples of HDMT organization and management that they would like to explore further. HDMTs can then utilize the local CoP platform to contact other members to learn more about their HDMT models. This process highlights the utility of the CoP platform in enabling peer-to-peer communication and exchange of information among groups who would otherwise have had no means of connecting and communicating. A systematic study of how CoP users utilize and act on data from Mobilization 2.0—including the changes they make to HDMT management and organization—is ongoing and will yield interesting insights about this method of data sharing in the near future.
Implementing a CoP: Some key considerations
Lead members of the CoP HSD identified a few main considerations and challenges in implementing this strategy of knowledge management and community building. Maintaining equality of voices is critical to the strategy, but saying that a CoP is horizontally structured does not necessarily translate into practice, making it important that facilitators actively promote the commitment to equality. The second key consideration is the political nature of creating these CoPs. There must be government central buy-in and involvement in order to legitimize the group and attract members, but the free exchange of ideas also necessitates that CoPs ultimately remain independent entities. A challenge of the HHA CoP model is that creating CoPs focusing only on a specific building block of the health system can also lead to siloes—one of the very issues that CoPs were designed to ameliorate. To counteract this, Harmonization for Health in Africa CoPs have recently begun to move to a matrix model through the creation of National Hubs, which bring together all members of the eight HHA CoPs who are working in a given country to share lessons from their individual groups and create synergy across the CoPs at the national level.
Community of Practice Meeting
Health systems in sub-Saharan Africa require innovations to accelerate progress toward improved primary care. The CoP HSD provides an innovative opportunity for frontline providers and policymakers to be empowered and to put their own stone at the foundation for building strong local health systems that can deliver quality health care to people in need.
Jean Paul Dossou, MD MPD, is a PhD student at the Centre de Recherche en Reproduction Humaine et en Démographie in Cotonou Benin and the Institute of Tropical Medicine of Antwerp-Belgium, as well as a co-facilitator of the Health Service Delivery Community of Practice.
Basile Keugoung, MD, MPH, PhD, is a lead facilitator of the Health Service Delivery Community of Practice.
Elisabeth Tadiri is a Primary Health Care Intern at Ariadne Labs, a joint center between Brigham and Women’s Hospital and the Harvard T. H Chan School of Public Health.
Hannah Ratcliffe, MSc is a Research Manager at Ariadne Labs.