There is no single solution for successfully scaling-up key interventions and reaching the poor. Implementation research, using tools and approaches that are inclusive, participatory, and flexible, is essential for “learning-by-doing” to understand what works best in a particular context.

Throughout the duration of the Future Health Systems project (FHS), country teams have committed to undertaking systematic learning though implementation research and by bringing together key actors involved in service delivery. In this Key Message Brief, we share some examples of how FHS teams have embodied a “learning-by-doing” approach, and what the consequences of this approach have been.UK Ai

Paina, Ligia

English

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Key messages
1 Often our assumptions about how a particular intervention will work prove to be inaccurate. Even where 
policies and programmes have sought to identify how they might affect the broader health system, there are 
often unpredictable effects. 
2 Implementation research allows us to learn from failure and adapt interventions in response to contextual 
changes – something that should become routine. Research and learning processes must run simultaneously 
with policy change and implementation. 
3 Policy reforms and designs must be flexible enough to accommodate responses to changes in the 
implementation environment. 
4 Health systems and policy researchers can play convening and advocacy roles, by bringing multiple health systems 
actors together, by providing lessons learned from implementation and evidence about poor and marginalized 
populations, and by finding innovative ways to showcase their voice in policy and management dialogue.
5 Continuous engagement of stakeholders must be achieved at multiple levels to ensure that lessons learned 
feed back into the policy and implementation processes.
How learning-by-doing can help 
cut through complexity in health 
service delivery
Key Message 
Brief Issue 1 | May 2016
1
FH
S
There is no single solution for successfully scaling-up key interventions and reaching the poor.  
Implementation research, using tools and approaches that are inclusive, participatory, and flexible, 
is essential for “learning-by-doing” to understand what works best in a particular context.
A pregnant woman 
is transported to 
a health clinic 
via boda boda in 
Eastern Uganda as 
part of an FHS pilot 
study on transport 
voucher schemes.
Introduction
Intervening in health systems in low- and middle-
income countries (LMICs) is complex. In many LMICs, 
health systems data are fragmented and incomplete, 
and therefore difficult to use well in decision-making. 
Too frequently, health system policies are created 
in silos that fail to consider how these new policies 
will interact with existing health and cross-sectoral 
policies. Furthermore, countries often cannot fully 
predict the impact (good and bad) of policy reforms 
and programmatic interventions that have been 
borrowed from other settings. Even when policy-
makers and program implementers try to anticipate 
how interventions might affect the broader health 
system, it is hard to do because of the dynamic 
nature of health systems and the contexts within 
which they exist. Getting the right stakeholders to 
agree and take action is also a challenge. Typically, 
lack of stakeholder engagement leads to limited buy-
in for policy implementation. Selective stakeholder 
engagement often leaves poor and marginalized 
populations out of the discussion, voiceless. 
As a result, many policies fail due to a lack of learning 
from how things do not work and the failure to bring 
in important stakeholder perspectives and resources 
to the decision-making table. A stronger and more 
systematic emphasis on learning is needed to better 
implement and scale-up life-saving health systems 
interventions.
Evidence
Throughout the duration of the Future Health 
Systems project (FHS), country teams have committed 
to undertaking systematic learning though 
implementation research and by bringing together key 
actors involved in service delivery. We share, below, 
some examples of how FHS teams have embodied 
a “learning-by-doing” approach, and what the 
consequences of this approach have been.
Engaging stakeholders: In Uganda, maternal 
mortality in rural areas remains stubbornly high, 
despite significant government and donor investments 
over time. Researchers from Makerere University 
School of Public Health are using a participatory 
action research approach to implement a package of 
complementary interventions to increase institutional 
deliveries in rural Uganda, through strengthening 
and building upon existing local resources. The team 
recognized the need to engage with stakeholders at 
multiple levels – policy-makers, district-health officials, 
community members – in order to understand the 
complex barriers to reducing maternal mortality and 
identify local resources, such as local savings groups 
and transport options, to overcome these barriers. 
The research team continues to examine how to 
better understand and engage with stakeholders 
using old and new tools – such as stakeholder 
analysis, participatory impact pathways analysis, 
and most significant change. Engagement with local 
stakeholders has informed how the intervention was 
adapted to better meet the needs of its beneficiaries. 
District health officials, for example, have been able 
to influence the research design and use the research 
project’s findings in their decision-making. Engaging 
with the community through the most significant 
change approach has provided early evidence of 
what is and is not working and the ability to adjust the 
intervention to better serve beneficiaries. 
Recognizing complexity and system-wide 
effects: In 2009, the Chinese government 
implemented widespread health system payment 
reforms as part of a broader package of health 
reforms designed to enhance financial protection 
and promote equity and quality of care. While these 
reforms were determined and announced nationally, 
they left significant discretion to county level officials 
in how to implement the reforms. The effects that 
a particular policy, such as payment reform, will 
have depend upon interactions with other parts 
of the broader health system: how resources are 
raised, services organized, 
essential drug policy, etc. 
The FHS China research 
team worked with officials 
in three counties to track the 
effects of early reforms and 
inform later rounds of policy 
and decision-making. Early 
findings from the research 
illustrated how the package of payment reforms had 
combined with a new policy of zero mark-up on 
drugs to influence how providers prescribe and admit 
patients, and how they charge patients for services, 
leading to unpredictable patient care outcomes. The 
team worked with local officials to explore policies 
that might mitigate these unanticipated and negative 
consequences of reform. 
 Future Health Systems Key Message Brief Issue 1 | May 2016 | www.futurehealthsystems.org
2
 FHS India 
Photovoice 
participants meet 
with the local 
self-government 
(panchayat) to 
discuss health 
issues highlighted 
through the 
Photovoice 
process.
FH
S
 A stronger and more 
systematic emphasis on 
learning is needed to 
better implement and 
scale-up life-saving health 
systems interventions. 
 For the things we have to 
learn before we can do them, 
we learn by doing them. 
(Aristotle, The Nicomachean Ethics)
Learning from negative results: While success 
often delivers learning, the failures that FHS has 
experienced are also very informative. For example, 
in Bangladesh, the research team partnered with 
a private telecommunications firm to implement a 
telemedicine initiative. The initiative aimed to improve 
the capacity of informal healthcare providers to 
adhere to treatment guidelines in rural Bangladesh, 
by linking them with trained providers. However, 
the team underestimated the trust necessary for 
telemedicine to work – patients were uncomfortable 
with not seeing the doctor in person. Furthermore, 
the partnership with the telecommunications firm was 
not successful. The research team re-evaluated the 
context, as well as new evidence on the population’s 
readiness to adopt mHealth technologies and village 
doctors’ experiences with, and perceptions of, the 
telemedicine intervention. Based upon this, the team 
decided to set up its own telemedicine centre at the 
International Centre for Diarrhoeal Disease Research, 
Bangladesh (ICDDR,b), and is also experimenting with 
the use of video conferencing to bring patients and 
providers closer together.
Feeding back knowledge into the system: 
In India, FHS facilitated the formation of a learning 
platform on child health in the Sundarbans area of 
West Bengal, comprised of a variety of health system 
actors. The Indian research team emphasized the 
importance of engaging directly with the community, 
using a two-pronged approach. First, it focused 
on empowering women to use participatory action 
research tools, such as Photovoice, to document 
and discuss the challenges they faced in accessing 
health services. The research team then facilitated 
face-to-face meetings with local officials where 
the women shared their findings. Simultaneously, 
the research team sought to build the capacity of 
local NGOs to interpret and apply findings from 
the evidence collected. This approach of engaging 
multiple stakeholders – decision-makers, end users 
and knowledge brokers – in a sharing 
and learning platform helped increase 
the likelihood of local investment in, 
demand for and use of health services. 
At the root of a “learning by doing” 
approach is a recognition that 
research teams and implementing partners need to 
continuously update expectations and assumptions 
about a policy or program. Structured processes that 
can capture and synthesize these expectations from the 
perspectives of multiple actors can be very beneficial. 
The FHS research teams have employed multiple tools 
to assist in this process, including theories of change, 
participatory impact pathways analysis, the most 
significant change technique and social mapping. 
With all of the interventions that FHS has directly 
supported, there have been significant shifts 
in strategy that have reflected new learning or 
emerging realities. As the Bangladesh and China 
examples above indicate, programmatic and policy 
strategies had to adapt when it was learned that 
people really needed to see an image of their 
health care provider in order to trust them, or when 
the unanticipated and negative consequences of 
provider payment reform in China were identified. 
Policy makers, funders and implementing teams 
need to be open to such flexibility and adaptation.
A “learning-by-doing” approach requires research 
teams to develop new competencies and adopt roles 
that they may be unaccustomed to. For example, FHS 
 Future Health Systems Key Message Brief Issue 1 | May 2016 | www.futurehealthsystems.org
3
 Learning 
should happen 
from success, as 
well as failure. 
The Makerere University’s School of Public Health-led intervention provided a package of complementary 
interventions to strengthen the health system in rural Uganda and support increased facility deliveries. To 
implement this intervention, the research team engaged national, district, and community members through 
participatory action research techniques. The research team provided mentorship and supportive supervision. 
The facilities and health workers who worked were thereafter motivated through recognition of best performing 
health workers and health facilities. FHS Uganda has moved from providing vouchers to pay for transport to 
health facilities, to getting people to save for facility-based deliveries, which may provide a basis for future 
health insurance schemes. FHS started off mentoring in only two facilities per district and then moved to four 
and is continuing to cover the district slowly, while learning from prior mistakes. The team used a multi-faceted 
approach that involved creating awareness, improving financial access and improving quality of maternal 
and child health care, and this yielded positive results. For example, by the end of the project, women in the 
intervention areas were 15% more likely to attend 4 ante-natal care visits, an important improvement from 
the baseline of 9%. Furthermore, facility-based deliveries increased from 66% to 72% in the intervention 
area, while actually going down a couple of points, from 65% to 63% in control areas. As far as possible, the 
Uganda team sought to build on existing resources and structures. So, for example, initially the team mainly 
drew upon nurse mentors from Kampala and Soroti districts to support the development of district mentors in 
the FHS districts. However, later it was realized that it would have been better to use regional mentors, as they 
could have continued to support the facilities in the focal districts. FHS is now seeking to equip facility managers 
to become supervisors and mentors because district officials are often unable to mentor and supervise due to 
lack of transport to get to the facilities.
Engaging policy and community stakeholders through multi-faceted interventions in 
order to increase skilled delivery in rural Uganda
 Future Health Systems Key Message Brief Issue 1 | May 2016 | www.futurehealthsystems.org
4
CREDITS
This Key Message 
Brief was prepared 
by Ligia Paina 
and is part of a 
series compiled by 
the Future Health 
Systems consortium.
This document has 
been funded by the 
UK Government. 
However, the views 
expressed herein 
are those of the 
author(s) and do 
not necessarily 
reflect those of the 
UK Government 
or the partners in 
the Future Health 
Systems research 
consortium.
This work is licenced 
under a Creative 
Commons Attribution-
NonCommercial 3.0 
Unported License. 
2016.
policy influence and research uptake managers 
have been integral members of country research 
teams, continuously striving to bridge the gap 
between policy and community actors, between 
researchers and implementers. These staff 
have continuously supported the engagement 
and briefing of relevant stakeholders about 
interventions and policy actions. The role of 
researchers may also need to evolve going beyond 
traditional publication of journal articles. Research 
cannot drive policy change unless researchers 
engage policy and community actors, and leverage 
and mobilize community capabilities. Researchers 
may have a particularly important advocacy role 
to play, for example providing evidence about how 
new programs affect women, or the vulnerable.
Future Health Systems is a research consortium working to improve access, affordability and quality of health services for the poor. We are a 
partnership of leading research institutes from across the globe, including: Johns Hopkins Bloomberg School of Public Health; China National 
Health Development Research Center; International Centre for Diarrhoeal Disease Research, Bangladesh; Institute of Development Studies, UK; 
Indian Institute of Health Management & Research; and Makerere University School of Public Health, Uganda.
futurehealthsystems@gmail.com
@futurehealthsys
www.facebook.com/futurehealthsys
www.futurehealthsystems.org
Based on their collective experience, the FHS teams found that:  
• Learning should happen from success, as well as failure. Learning processes should run simultaneous 
with policy changes.
• Flexibility in research design allows implementers to be sensitive to local realities and to modify plans 
to suit the situation, as well as to be responsive to policy priorities.  
• Flexibility in the design of policies also allows decision-makers to be able to use emerging evidence in 
the on-going implementation of policies.  
• The inclusion of multiple stakeholder perspectives, through purposeful stakeholder engagement, as 
well as identification of the barriers that they face and resources they possess, is important and can 
lead to improvements in service delivery outcomes.
• Long-term engagement allows for higher order learning and for new interventions to grow and 
become embedded within existing structures, promoting sustainability.  
• Researchers can play an important role by engaging with other system actors. Further support to 
strengthening research skills for adequate engagement and advocacy is necessary.  
• Researchers act as change agents and facilitate the “learning-by-doing” process. The development of 
learning platforms that incorporate multiple perspectives through innovative research techniques can bridge 
the evidence-to-practice gap and can ensure that the research reflects both policy and community priorities.
Conclusions
Key references
Bramhachari, R. (2016) ‘Incorporating Rural Medical Practitioners to Shore up Universal Health Coverage’, FHS Blog
Ekirapa-Kiracho, E. ; Kiwanuka, S. ; Waiswa, P. ; Namazi, G. ; Makumbi, F. ; Atuyambe, L. ; Judith, A. ; George, A. ; John, O. ; John, B. ; Aloysius, 
M. ; Tetui, M. and Kananura, R.M. (2016) ‘Maternal and Newborn Interventions for Equitable Systems Study Endline Evaluation Report’, Makerere 
University School of Public Health, Kampala, Uganda
Kanjilal, B.; Bose, S.; Patra, N.; Barman, D.; Ghosh, U.; Mandal, A.; Vadrevu, L.S. and Sengupta, P. (2013) ‘The Sundarbans Health Watch Report 
Series: 1. How Healthy are the Children of Indian Sundarbans?’ Institute of Health Management Research (IIHMR), Jaipur, India
Khan, N.U.Z.; Rasheed, S.; Sharmin, T.; Ahmed, T.; Mahmood, S.S.; Khatun, F.; Hanifi, S.M.A.; Hoque, S.; Iqbal, M. and Bhuiya, A. (2015) ‘Experience 
of using mHealth to link village doctors with physicians: lessons from Chakaria, Bangladesh’, BMC Medical Informatics and Decision Making, 15:62, 
doi:10.1186/s12911-015-0188-9
Khatuna, F.; Heywood, A.E.; Ray, P.K.; Hanifi, S.M.A.; Bhuiya, A. and Liaw, S.T. (2015) ‘Determinants of readiness to adopt mHealth in a rural community 
of Bangladesh’, International Journal of Medical Informatics, Volume 84, Issue 10, Pages 847–856, http://dx.doi.org/10.1016/j.ijmedinf.2015.06.008
Xiao, Y.; Zhao, K.; Bishai, D. and Peters, D. (2012) ‘Essential drugs policy in three rural counties in China: What does a complexity lens add?’ Social 
Science & Medicine, Volume 93, September 2013, Pages 220-228
Tools and approaches
Most Significant Change Technique, Accessible at: http://betterevaluation.org/resources/guide/most_significant_change_technique
Photovoice, Accessible at: http://betterevaluation.org/resources/website/PhotoVoice
Theory of Change, Accessible at: http://betterevaluation.org/resources/guide/theory_of_change
Participatory Impact Pathways Analysis, Accessible at: http://betterevaluation.org/resources/guides/impact_pathways
Social Mapping, Accessible at: http://betterevaluation.org/evaluation-options/socialmapping


How Learning-by-Doing Can Help Cut Through Complexity in Health Service Delivery

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How Learning-by-Doing Can Help Cut Through Complexity in Health Service Delivery

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