What does it take to influence change at a system-wide scale? How can a collaborative enterprise be generated across interdependent healthcare organizations?

Research teams across Africa are concerned about the role of research in influencing health systems strengthening and performance goals. Research investments have been channeled into reforms and pilots such as social health insurance, performance-based financing and community health programs with a goal to influence system-wide goals such as universal health coverage, improved child survival and maternal health outcomes. As the findings from these research undertakings become clear, the breadth of their implications becomes a daunting challenge for researchers as well as policymakers

For example, findings from a health system research effort in Ghana recommended increase in quality of services and a reduction of cost of medical care [see study here and here].  To influence policy, the research groups in Ghana would have to engage with the insurance agency, the association of hospital-level managers, NGOs representing patients’ rights, the ministries of Health, Finance, Public Service and key agencies dealing with the procurement of medical products, professional associations and health worker Unions. In short, the application of research findings from these studies requires attention and synergistic actions from 10 to 15 key stakeholder groups to successfully attain the goal of raising the service quality and reducing medical care costs.

One fundamental feature of health systems and policy research is the multiplicity of the actors necessary for the attainment of system-wide goals in public health. In a system, the application of evidence (or innovations) rarely works within the confines of a single organization. If this were true, health system researchers would just need to arrange a meeting with the Chief Executive Officer (CEO) of the affected organization to share their findings and let the CEO take the appropriate decisions. For system-wide changes, however, many different groups need to be identified, and brought to the table for meaningful dialogue. In reality each actor group may have slight or fundamentally different interests, values, resources and power.  Management scientists have expressed system-wide problems where performance goals require multiple actors with different values, interest and power as “wicked problems”.  Many public health and health systems innovation fall within this domain.

So how does the health system researcher play some constructive roles in: 1) mobilizing a multitude of stakeholders to use evidence for system-wide problem solving, 2) assembling all the pieces of the implementation jigsaw and 3) orchestrating effective performance of policy programs?

Specifically for the above example, how can the research teams in Ghana get the decisions to support sustainable quality improvements and cost controls that will meet the interests and expectations of all groups with a legitimate stake in these decisions? Should research experts get involved in all these activities? The usual escape route for researchers is to push research findings into a journal and hope that the concerned decision makers will stumble upon the journal, locate the article, read it and take the appropriate decisions as recommended therein.

This approach has been branded “to whom it may concern” to symbolize the lack of purposive customization of decision-making to particular contexts or real life situations. Research funders are now pushing research practitioners to go the extra mile and influence the uptake of their research by influencing polices, programs and practices for better health outcomes.

The good news is that scientists and experts who deal with “wicked problems” on a routine basis have devised systematic ways to generate impacts at a system-wide scale. In general terms, the solution involve identification and engagement of major stakeholders [see reference here] The main theory is that together and in a collaborative fashion stakeholders develop a shared understanding of the problem, craft common goal(s), learn about the feasible options available (solutions) and make decisions they are prepared to own and implement in a collaborative way.

To arrive at this stage, there are deliberate efforts that research teams (and their coalitions) need to undertake. In broad terms, the process involves the following principles [see reference here]:

1. CAREFUL PLANNING AND PREPARATION: Through adequate and inclusive planning, ensure that the design, organization, and convening of the process serve both a clearly defined purpose and the needs of the participants.
2. INCLUSION AND DIVERSITY: Legitimate stakeholder e.g experts, clients, organizations, ideas, and information to lay the groundwork for legitimacy decisions and outcomes.
3.  COLLABORATION AND SHARED PURPOSE: Support and encourage participants, government and community institutions, and others to work together to advance the common good and goals thereof.
4. OPENNESS AND LEARNING: Help all involved to listen to each other, explore new ideas unconstrained by predetermined interests, learn and apply information in ways that generate new options, and rigorously evaluate public engagement activities for effectiveness.
5. TRANSPARENCY AND TRUST: Be clear and open about the process, and provide a public record of the organizers, sponsors, outcomes, and range of views and ideas expressed.
6. IMPACT AND ACTION: Ensure each participatory effort has real potential to make a difference, and that participants are aware of that potential and results.
7. SUSTAINED ENGAGEMENT AND PARTICIPATORY CULTURE: Promote a culture of participation with programs and institutions that support ongoing quality public engagement.

Key Message:

With a little extra time, interest, resources and collaborators, research experts have the potential to play a brokerage role by creating opportunities for stakeholders to engage in fruitful and legitimate dialogue to learn and collaboratively generate effective system-wide solutions for complex public health problems.  As we think about universal health coverage and similar system-wide goals, the principles above can guide the means of attaining these goals.