What are the consequences of the false dichotomy between global and local knowledge in health systems

Why guidelines fail: on consequences of the false dichotomy between global and local knowledge in health systems

Global health

Global health continues to grapple with a persistent tension between standardized, evidence-based interventions developed by international experts and the contextual, experiential local knowledge held by local health workers. This dichotomy – between global expertise and local knowledge – has become increasingly problematic as health systems face unprecedented complexity in addressing challenges from climate change to emerging diseases.

The limitations of current approaches

The dominant approach privileges global technical expertise, viewing local knowledge primarily through the lens of “implementation barriers” to be overcome. This framework assumes that if only local practitioners would correctly apply global guidance, health outcomes would improve.

This assumption falls short in several critical ways:

  1. It fails to recognize that local health workers often possess sophisticated understanding of how interventions need to be adapted to work in their contexts.
  2. It overlooks the way that local knowledge, built through direct experience with communities, often anticipates problems that global guidance has yet to address.
  3. It perpetuates power dynamics that systematically devalue knowledge generated outside academic and global health institutions.

The hidden costs of privileging global expertise

When we examine actual practice, we find that privileging global over local knowledge can actively harm health system performance:

  • It creates a “capability trap” where local health workers become dependent on external expertise rather than developing their own problem-solving capabilities.
  • It leads to the implementation of standardized solutions that may not address the real needs of communities.
  • It demoralizes community-based staff who see their expertise and experience consistently undervalued.
  • It slows the spread of innovative local solutions that could benefit other contexts.

Evidence from practice

Recent experiences from the COVID-19 pandemic provide compelling evidence for the importance of local knowledge. While global guidance struggled to keep pace with evolving challenges, local health workers had to figure out how to keep health services going:

  • Community health workers in rural areas adapted strategies.
  • District health teams created new approaches to maintain essential services during lockdowns.
  • Facility staff developed creative solutions to manage PPE shortages.

These innovations emerged not from global technical assistance, but from local practitioners applying their deep understanding of community needs and system constraints, and by exploring new ways to connect with each other and contribute to global knowledge.

Towards a new synthesis

Rather than choosing between global and local knowledge, we need a new synthesis that recognizes their complementary strengths. This requires three fundamental shifts:

1. Reframing local knowledge

  • Moving from viewing local knowledge as merely contextual to seeing it as a source of innovation.
  • Recognizing frontline health workers as knowledge creators, not just knowledge recipients.
  • Valuing experiential learning alongside formal evidence.

2. Rethinking technical assistance

  • Shifting from knowledge transfer to knowledge co-creation.
  • Building platforms for peer learning and exchange.
  • Supporting local problem-solving capabilities.

3. Restructuring power relations

  • Creating mechanisms for local knowledge to inform global guidance.
  • Developing new metrics that value local innovation.
  • Investing in local knowledge documentation and sharing.

Practical implications

This new synthesis has important practical implications for how we approach health system strengthening:

Investment priorities

  • Funding mechanisms need to support local knowledge creation and sharing
  • Technical assistance should focus on building local problem-solving capabilities
  • Technology investments should enable peer learning and knowledge exchange

Capacity building

Knowledge management (KM)

New paths forward

Moving beyond the false dichotomy between global and local knowledge opens new possibilities for strengthening health systems. By recognizing and valuing both forms of knowledge, we can create more effective, resilient, and equitable health systems.

The challenges facing health systems are too complex for any single source of knowledge to address alone. Only by bringing together global expertise and local knowledge can we develop the solutions needed to improve health outcomes for all.

References

Braithwaite, J., Churruca, K., Long, J.C., Ellis, L.A., Herkes, J., 2018. When complexity science meets implementation science: a theoretical and empirical analysis of systems change. BMC Med 16, 63. https://doi.org/10.1186/s12916-018-1057-z

Farsalinos, K., Poulas, K., Kouretas, D., Vantarakis, A., Leotsinidis, M., Kouvelas, D., Docea, A.O., Kostoff, R., Gerotziafas, G.T., Antoniou, M.N., Polosa, R., Barbouni, A., Yiakoumaki, V., Giannouchos, T.V., Bagos, P.G., Lazopoulos, G., Izotov, B.N., Tutelyan, V.A., Aschner, M., Hartung, T., Wallace, H.M., Carvalho, F., Domingo, J.L., Tsatsakis, A., 2021. Improved strategies to counter the COVID-19 pandemic: Lockdowns vs. primary and community healthcare. Toxicology Reports 8, 1–9. https://doi.org/10.1016/j.toxrep.2020.12.001

Jerneck, A., Olsson, L., 2011. Breaking out of sustainability impasses: How to apply frame analysis, reframing and transition theory to global health challenges. Environmental Innovation and Societal Transitions 1, 255–271. https://doi.org/10.1016/j.eist.2011.10.005

Salve, S., Raven, J., Das, P., Srinivasan, S., Khaled, A., Hayee, M., Olisenekwu, G., Gooding, K., 2023. Community health workers and Covid-19: Cross-country evidence on their roles, experiences, challenges and adaptive strategies. PLOS Glob Public Health 3, e0001447. https://doi.org/10.1371/journal.pgph.0001447

Yamey, G., 2012. What are the barriers to scaling up health interventions in low and middle income countries? A qualitative study of academic leaders in implementation science. Global Health 8, 11. https://doi.org/10.1186/1744-8603-8-11

Ahead of Teach to Reach 11, health leaders from 45 countries share malaria solutions in REACH network session

Ahead of Teach to Reach 11, health leaders from 45 countries share malaria experiences in REACH network session

Global health

Nearly 300 malaria prevention health leaders from 45 countries met virtually on November 20, 2024, in parallel English and French sessions of REACH. This new initiative connects organizational leaders tackling malaria prevention and control – and other pressing health challenges – across borders. REACH emerged from Teach to Reach, a peer learning platform with over 23,000 health professionals registered for its eleventh edition on 5-6 December 2024.

The sessions connected community-based health workers with health leaders from districts to national planners from across Africa, Asia, and South America, bringing together government health staff, civil society organizations, teaching hospitals, and international agencies, in a promising cross-section of local-to-global health expertise.

Global partnership empowers malaria prevention health leaders

The sessions featured RBM Partnership to End Malaria as Teach to Reach’s newest global partner, ahead of a special event on malaria planned for December 10. Read about the RBM-TGLF Partnership…

Request your invitation for the special event on malaria: https://www.learning.foundation/malaria

“To end malaria, we must empower the people closest to the problem – health workers in affected communities,” said Antonio Pizzuto, Partnership Manager at RBM. “[Teach to Reach] allows us to listen to and learn from those on the frontlines of malaria control, ensuring their voices drive our global strategies.”

Watch the REACH session focused on health leaders sharing experience to end malaria

Voir la version française de cet événement

Community health leaders report prevention challenges

Health leaders described persistent challenges in malaria prevention, particularly around mosquito net usage.

“For the mosquito nets, majority of them, mostly those who don’t come to hospital regularly, use it to do their fish ponds. Some use it to do their vegetables,” reported Ajai Patience, who works with WHO in Nigeria. Her team countered this through targeted education: “At antenatal level, we try to make them understand the importance of not having malaria in pregnancy. By the time we give them this health talk, they now calm down to use their mosquito nets. We visit them in the communities to see what they are doing.”

In Burkina Faso, where pregnancy care is free, similar challenges persist. “Unfortunately, some don’t use their insecticide-treated nets or take their medication during pregnancy,” said Sophie Ramde, Head of Reproductive Health Services. “This remains a challenge in our region, especially with heavy rainfall.”

What do health leaders do when there are malaria medicine or supply shortages?

Leaders shared various approaches to medicine and supply shortages.

“If we don’t have medicines, we request to borrow from other international NGOs,” explained Geoffray Kakesi, Chief of Mission for ALIMA in Mali.

In DRC, Dr. Mathieu Kalemayi organized a “watch party” for this REACH session, joining with a group of 11 CSO leaders. He explained how the Ministry of Health in his district works together with CSOs on mosquito net distribution: “These organizations play a major role in community sensitization… We’ve taken the initiative to meet each time there’s a session.”

What are barriers to access?

Distance to treatment emerged as a critical challenge. Professor Beckie Tagbo from Nigeria’s University Teaching Hospital shared this example, shared by a colleague during the REACH networking session : “He works in a primary health care center unable to treat severe malaria. Patients must travel 60-70 kilometers to higher centers for treatment, and some lack the funds.”

In Chad, one organization adapted by embedding healthcare workers in communities. “We live with these volunteer nurses in the villages to provide care, with community relays distributing medicines to anyone showing signs of simple malaria,” explained Moguena Koldimadji, Coordinator of the Collective of United Health and Social Workers for Care Improvement and Enhancement.

How is climate change affecting malaria patterns?

Participants noted shifting disease patterns due to climate change. “Unlike previous years, malaria now occurs in high altitude areas and in patients who have no travel history,” reported Mersha Gorfu, who works for WHO in Ethiopia.

What is the value of community engagement?

Some organizations reported success through structured outreach programs. In Kenya, Taphurother Mutange, a Community Health Worker with Kenya’s Ministry of Health, described their approach: “We have been subdivided into units as health workers. I’ve been given 100 households I visit every week. When they have problems or are sick, I refer them. When there were floods, we were given tablets to give community members to treat water.”

How do health workers cope personally with malaria?

Arthur Fidelis Metsampito Bamlatol, Coordinator of AAPSEB (Association for Support to Health, Environment and Good Governance Promotion) in Cameroon’s East Region, shared how personal experience shaped his work: “I had a severe malaria episode. I was shivering, trembling. It hit me hard with waves of heat washing over me… I had to take six doses of IV treatment. Since then, I’ve been advised to sleep under mosquito nets every night, along with my family members. In our association, this is one of the key messages we bring to communities.”

What is the value of learning across geographic borders?

Malaria prevention health leaders identified similar challenges across countries. “The challenges in DRC can be the same as in Ivory Coast and what is done in Ivory Coast can also help address challenges in DRC,” noted Patrice Kazadi, Project Director at Save the Children International DRC.

What’s next for health leaders?

Health leadership is more needed than ever to drive innovation and collaboration to tackle this global challenge.

The next REACH session, scheduled for November 27, will focus on climate and health risks and barriers, in partnership with Grand Challenges Canada (GCC). Learn more about the partnership with GCC…

This is all building up to Teach to Reach’s 11th edition on December 5-6 and the special malaria event on December 10.

Health professionals can request invitations at www.learning.foundation/teachtoreach

Learn more about the Teach to Reach Special Event for Malaria: https://www.learning.foundation/malaria

Teach to Reach Health workers are sharing how they protected their communities when extreme weather hit

You are not alone: Health workers are sharing how they protected their communities when extreme weather hit

Global health

Today, The Geneva Learning Foundation launched a new set of “Teach to Reach Questions” focused on how health workers protect community health during extreme weather events. This initiative comes at a crucial time, as world leaders at COP29 discuss climate change’s mounting impacts on health.

As climate change intensifies extreme weather events worldwide, health workers are often the first to respond when disasters strike their communities. Their experiences – whether facing floods, droughts, heatwaves, or storms – contain vital lessons that could help others prepare for and respond to similar challenges.

Read the eyewitness report: From community to planet: Health professionals on the frontlines of climate change, Online. The Geneva Learning Foundation. https://doi.org/10.5281/zenodo.10204660

Why ask health workers about floods, droughts, and heatwaves?

“Traditional surveys often ask for general information or statistics,” explains Charlotte Mbuh of The Geneva Learning Foundation. “Teach to Reach Questions are different. We ask health workers to share specific moments – a time when they had to act quickly during a flood, or how they kept services running during a drought. These stories reveal not just what happened, but how people actually solved problems on the ground.”

The questions cover six key scenarios:

  1. Disease outbreaks during floods
  2. Health impacts of drought
  3. Care delivery during heatwaves
  4. Mental health support before, during, and after
  5. Maintaining healthcare access
  6. Quick action and local solutions to protect health

Each scenario includes detailed prompts that help health workers recall and share the specifics of their experience: What exactly did they do? Who helped? What obstacles did they face? How did they know their actions made a difference?

Strengthening local action: From individual experience to collective learning to protect community health

What makes Teach to Reach Questions unique is not just how they are asked, but what happens next. Every experience shared becomes part of a larger learning process that benefits the entire community.

“We don’t just collect these experiences – we give them back,” says Reda Sadki, President of The Geneva Learning Foundation. “Whether someone shares their own story or not, they gain access to the complete collection of experiences. This creates a virtuous cycle of peer learning, where solutions discovered in one community can help another on the other side of the world.”

The process unfolds in four phases:

  1. Experience Collection: Health workers share their stories through structured questions ahead of the live Teach to Reach event
  2. Live Event: During the Teach to Reach live event, Contributors who shared their experience are invited to do so in plenary sessions. Everyone can listen in – and join one-to-one networking sessions to learn from the experiences of colleagues from all over the world.
  3. Analysis and Synthesis: After the live event, the Foundation’s Insights team works with the Teach to Reach community to identify patterns, innovations, and key lessons
  4. Knowledge Sharing: Insights are returned to the community through comprehensive collections of experiences, thematic insights reports, and Insights Live sessions

Building momentum for Teach to Reach 11

These questions are part of the lead-up to Teach to Reach 11, scheduled for December 5-6, 2024. The experiences shared will inform discussions among the 23,000+ registered participants from over 70 countries.

“But the learning starts now,” emphasizes Mbuh. “Health workers who request their invitation today can immediately begin sharing and learning from peers. The earlier they join, the more they can benefit from this collective knowledge exchange.”

Why protecting community health against extreme weather events matters

As extreme weather events become more frequent and severe, the expertise of health workers who have already faced these challenges becomes increasingly valuable.

“These aren’t just stories – they’re a vital source of knowledge for protecting community health in a changing climate,” says Sadki. “By sharing them widely, we help ensure that health workers everywhere are better prepared when extreme weather strikes their communities.”

Health professionals interested in participating can request their invitation.

Listen to the Teach to Reach podcast:

Is your organisation interested in learning from health workers? Learn more about becoming a Teach to Reach partner.

Image: The Geneva Learning Foundation Collection © 2024

Why answer Teach to Reach Questions-small

Why answer Teach to Reach Questions?

Global health

Have you ever wished you could talk to another health worker who has faced the same challenges as you? Someone who found a way to keep helping people, even when things seemed impossible? That’s exactly the kind of active learning that Teach to Reach Questions make possible. They make peer learning easy for everyone who works for health.

What are Teach to Reach Questions?

Once you join Teach to Reach (what is it?), you’ll receive questions about real-world challenges that matter to health professionals.

How does it work?

  1. You choose what to share: Answer only questions where you have actual experience. No need to respond to everything – focus on what matters to you.
  2. Share specific moments: Instead of general information, we ask about real situations you’ve faced. What exactly happened? What did you do? How did you know it worked?
  3. Learn from others: Within weeks, you’ll receive a collection of experiences shared by health workers from over 70 countries. See how others solved problems similar to yours.

What’s different about these questions?

Unlike typical surveys that just collect data, Teach to Reach Questions are active learning that:

  • Focus on your real-world experience.
  • Help you reflect on what worked (and what didn’t).
  • Connect you to solutions from other health workers.
  • Give back everything shared to help everyone learn.

See what we give back to the community. Get the English-language collection of Experiences shared from Teach to Reach 10. The new compendium includes over 600 health worker experiences about immunisation, climate change, malaria, NTDs, and digital health. A second collection of more than 600 experiences shared by French-speaking participants is also available.

What’s in it for you?

Peer learning happens when we learn from each other. Your answers can help others – and their answers can help you.

  1. Get recognized: You’ll be honored as a Teach to Reach Contributor and receive certification.
  2. Learn practical solutions: See how other health workers tackle challenges like yours.
  3. Make connections: At Teach to Reach, you’ll meet others who have been sharing and learning about the same issues.
  4. Access support: Global partners will share how they can support solutions you and other health workers develop.

A health worker’s experience

Here is what on community health worker from Kenya said:

“When flooding hit our area, I felt so alone trying to figure out how to keep helping people. Through Teach to Reach, I learned that a colleague in another country had faced the same problem. Their solution helped me prepare better for the next flood. Now I’m sharing my experience to help others.”

Think about how peer learning could help you when more than 23,000 health professionals are asked to share their experience on a challenge that matters to you.

Ready to start?

  1. Request your invitation to Teach to Reach now.
  2. Look for questions in your inbox.
  3. Share your experience on topics you know about.
  4. Receive the complete collection of shared experiences.
  5. Join us in December to meet others face-to-face.

Remember: Your experience, no matter how small it might seem to you, could be exactly what another health worker needs to hear.

The sooner you join, the more you’ll learn from colleagues worldwide.

Together, we can turn what each of us knows into knowledge that helps everyone.

Listen to the Teach to Reach podcast:

Is your organisation interested in learning from health workers? Learn more about becoming a Teach to Reach partner.

Image: The Geneva Learning Foundation Collection © 2024

Health at COP29

Health at COP29: Workforce crisis meets climate crisis

Global health

Health workers are already being transformed by climate change. COP29 stakeholders can either support this transformation to strengthen health systems, or risk watching the health workforce collapse under mounting pressures.

The World Health Organization’s “COP29 Special Report on Climate Change and Health: Health is the Argument for Climate Action“ highlights the health sector’s role in climate action.

Health professionals are eyewitnesses and first responders to climate impacts on people and communities firsthand – from escalating respiratory diseases to spreading infections and increasing humanitarian disasters.

The report positions health workers as “trusted members of society” who are “uniquely positioned” to champion climate action.

The context is stark: WHO projects a global shortage of 10 million health workers by 2030, with six million in climate-vulnerable sub-Saharan Africa. Meanwhile, our communities and healthcare systems already bear the costs of climate change through increasing disease burdens and system strain.

Health workers are responding, because they have to. Their daily engagement with climate-affected communities offers insights that can strengthen both health systems and climate response – if we learn to listen.

A “fit-for-purpose” workforce requires rethinking learning and leadership

WHO’s report acknowledges that “scale-up and increased investments are necessary to build a well-distributed, fit-for-purpose workforce that can meet accelerating needs, especially in already vulnerable settings.” The report emphasizes that “governments and partners must prioritize access to decent jobs, resources, and support to deliver high-quality, climate-resilient health services.” This includes ensuring “essential protective equipment, supplies, fair compensation, and safe working conditions such as adequate personnel numbers, skills mix, and supervisory capacity.”

Resources, skills, and supervision are building blocks of every health system.

They are necessary but likely to be insufficient.

Such investments could be maximized through cost-effective, scalable peer learning networks that enable rapid knowledge sharing and solution development – as well as their locally-led implementation.

The WHO report calls for “community-led initiatives that harness local knowledge and practices.”

Our analyses – formed by listening to and learning from thousands of health professionals participating in the Teach to Reach peer learning platform – suggest that the expertise developed by health professionals through daily engagement with communities facing climate impacts is key to problem-solving, to implementing local solutions, and to ensure that communities are part and parcel of such solutions.

Why move beyond seeing health workers as implementers of policies or recipients of training?

We stand to gain much more if their leadership is recognized, nurtured, and supported.

This is a notion of leadership that diverges from convention: if health workers have leadership potential, it is because they are uniquely positioned to turn what they know – because they are there every day – into action.

Peer learning has the potential to significantly accelerate progress toward country and global goals for climate change and health.

By making connections, a health professional expands the horizon of what they are able to know.

At the Geneva Learning Foundation, we have seen that such leadership emerges when health workers are empowered to:

  • share and validate their experiential knowledge;
  • develop, test, and implement solutions with the communities they serve, using local resources;
  • connect with peers facing similar challenges; and
  • inform policy based on ground-level realities.

Working with a global community of community-based health workers, we co-developed the Teach to Reach platform, community, and network to listen and learn at scale. Unlike traditional training programs, Teach to Reach creates a peer learning ecosystem where:

  • Health workers from over 70 countries connect directly to share experiences.
  • Solutions are crowdsourced from those closest to the challenges.
  • Knowledge flows horizontally rather than just vertically.
  • Local innovations are rapidly shared and adapted across contexts.

For example, in June 2024, over 21,000 health professionals participated in Teach to Reach 10, generating hundreds of real-world stories and insights about climate change impacts on health.

The platform has proven particularly valuable in fragile contexts and resource-limited settings, where traditional capacity building approaches often struggle to reach or engage health workers effectively.

This approach does not replace formal institutions or traditional scientific methods – instead, it creates new pathways for knowledge to flow rapidly between communities, while building the collective capacity needed to respond to accelerating climate impacts on health.

Already, this demonstrates the untapped potential for health workers to contribute to our collective understanding and response.

But we do not stop there.

As we count down to Teach to Reach 11, participants are now sharing how they have actually used and applied this peer knowledge to make progress against their local challenges.

They cannot do it alone.

This is why we ask global partners to join and contribute to this emergent, locally-led leadership for change.

How different is this ‘ask’ from that of global partners asking health workers to contribute to the climate change and health agenda?

WHO’s COP29 report makes a powerful case that “community-led initiatives that harness local knowledge and practices in both climate action and health strategies are fundamental for creating interventions that are both culturally appropriate and effective.”

Furthermore, it recognizes that “these initiatives ensure that climate and health solutions are tailored to the specific needs and realities of those most impacted by climate change but also grounded in their lived realities.”

What framework for collaboration?

The path forward requires what the report describes as “cooperation across sectors, stakeholders and rights-holders – governmental institutions, local authorities, local leaders including religious authorities and traditional medicine practitioners, NGOs, businesses, the health community, Indigenous Peoples as well as local communities.”

Our experience with Teach to Reach demonstrates how such cooperation can be facilitated at scale through digital platforms that enable peer learning and knowledge sharing. Key elements include:

  • a structured yet flexible framework for sharing experiences and insights;
  • direct connections between health workers at all levels of the system;
  • rapid feedback loops between local implementation and broader learning;
  • support for health workers to document and share their innovations; and
  • mechanisms to validate and spread effective local solutions.

WHO’s recognition that health workers have “a moral, professional and public responsibility to protect and promote health, which includes advocating for climate action, leveraging prevention for climate mitigation and cost savings, and safeguarding healthy environments” sets a clear mandate.

This WHO report highlights the need for new ways of supporting community-led learning and action to:

  1. support the rapid sharing of local solutions;
  2. build health worker capacity through peer learning;
  3. connect communities facing similar challenges; and
  4. enable health workers to lead change in their communities

Reference

Neira, M. et al. (2024) COP 29 Special Report on Climate Change and Health: Health is the Argument for Climate Action. Geneva, Switzerland: World Health Organization.

Image: The Geneva Learning Foundation Collection © 2024

ASTMH 2024 How can we reliably spread evidence-based practices at the speed and scale modern health challenges demand

How can we reliably spread evidence-based practices at the speed and scale modern health challenges demand?

Global health

At a symposium of the American Society for Tropical Medicine and Hygiene (ASTMH) Annual Meeting, I explored how peer learning could help us tackle five critical challenges that limit effectiveness in global health.

  1. Performance: How do we move beyond knowledge gains to measurable improvements in health outcomes?
  2. Scale and access: How do we reach and include tens of thousands of health workers, not just dozens?
  3. Applicability: How do we ensure learning translates into changed practice?
  4. Diversity: How do we leverage different perspectives and contexts rather than enforce standardization?
  5. Complexity: How do we support locally-led leadership for change to tackle complex challenges that have no standard solutions?

For epidemiologists working on implementation science, peer learning provides a new path for solving one of global health’s most persistent challenges: how to reliably spread evidence-based practices at the speed and scale modern health challenges demand.

The evidence suggests we should view peer learning not just as a training approach, but as a mechanism for viral spread of effective practices through health systems.

How do we get to attribution?

Of course, an epidemiologist will want to know if and how improved health outcomes can be attributed to peer learning interventions.

The Geneva Learning Foundation (TGLF) addresses this fundamental challenge in implementation science – proving attribution – through a three-stage process that combines quantitative indicators with qualitative validation.

The process begins with baseline health indicators relevant to each context (such as vaccination coverage rates, if it is immunization), which are then tracked through regular “acceleration reports” that capture both metrics and implementation progress.

Rather than assuming causation from correlation, participants must explicitly rate the extent to which they attribute observed improvements to their intervention.

The critical innovation comes in the third stage: those claiming attribution must “prove it” to the community of peers, by providing specific evidence of how their actions led to the observed changes – a requirement that both controls for self-reporting limitations and generates rich qualitative data about implementation mechanisms.

This methodology has proven particularly valuable in complex interventions where randomized controlled trials may be impractical or insufficient.

What are examples of peer learning in action?

Here are three examples from The Geneva Learning Foundation’s work that demonstrate scale, reach, and sustainability.

Within four weeks, a single Teach to Reach cohort of 17,662 health workers across over 80 countries generated 1,800 context-specific experiences describing the “how” of implementation, especially at the district and community levels.

In Côte d’Ivoire, working with Gavi and The Geneva Learning Foundation, the national immunization team used TGLF’s model to support community engagement. Within two weeks, over 500 health workers representing 85% of the country’s districts had begun implementing locally-led innovations. 82% of participants said they would use TGLF’s model for their own needs, without requiring any further assistance or support.

In TGLF’s COVID-19 Peer Hub, 30% of participants successfully implemented recovery plans within three months – a rate seven times higher than a control group that did not use TGLF’s model.

Participants who actively engaged with peers were not only more likely to report successful implementation, but could demonstrate concrete evidence of how peer interactions contributed to their success, creating a robust framework for understanding not just whether interventions work, but how and why they succeed or fail across different contexts.

Quantifying learning

Using a simple methodology that measures learning efficacy across five key variables – scalability, information fidelity, cost effectiveness, feedback quality, and uniformity – we calculated that properly structured peer learning networks achieve an efficacy score of 3.2 out of 4, significantly outperforming both traditional cascade training (1.4) and expert coaching (2.2).

But the real breakthrough came when considering scale. When calculating the Efficacy-Scale Score (ESS) – which multiplies learning efficacy by the number of learners reached – the differences became stark:

  • Peer Learning: 3,200 (reaching 1,000 learners)
  • Cascade Training: 700 (reaching 500 learners)
  • Expert Coaching: 132 (reaching 60 learners)

Learn more: Calculating the relative effectiveness of expert coaching, peer learning, and cascade training

The mathematics of scale

For epidemiologists, the mechanics of this scaling effect may feel familiar.

In traditional expert-led training, if N is the total number of learners and M is the number of available experts who can each effectively coach K learners, we quickly hit a ceiling where N far exceeds M×K.

TGLF’s model transforms this equation by structuring interactions so each learner gives and receives feedback from exactly three peers, guided by expert-designed rubrics.

This creates a linear scaling pattern where total learning interactions = 3N, allowing for theoretically unlimited scale while maintaining quality through structured feedback loops.

Information loss and network resilience

One of the most interesting findings concerns information fidelity. In cascade training, knowledge degradation follows a predictable pattern:

K_n = K \cdot \alpha^n

where Kn is the knowledge at the nth level of the cascade and α is the loss rate at each step. This explains why cascade training, despite its theoretical appeal, consistently underperforms.

In contrast, TGLF’s peer learning-to-action networks showed remarkable resilience. By creating multiple pathways for knowledge transmission and building in structured feedback loops, the system maintains high information fidelity even at scale.

Learn more: Why does cascade training fail?

References

Arling, P.A., Doebbeling, B.N., Fox, R.L., 2011. Improving the Implementation of Evidence-Based Practice and Information Systems in Healthcare: A Social Network Approach. International Journal of Healthcare Information Systems and Informatics 6, 37–59. https://doi.org/10.4018/jhisi.2011040104

Hogan, M.J., Barton, A., Twiner, A., James, C., Ahmed, F., Casebourne, I., Steed, I., Hamilton, P., Shi, S., Zhao, Y., Harney, O.M., Wegerif, R., 2023. Education for collective intelligence. Irish Educational Studies 1–30. https://doi.org/10.1080/03323315.2023.2250309

Watkins, K.E., Sandmann, L.R., Dailey, C.A., Li, B., Yang, S.-E., Galen, R.S., Sadki, R., 2022. Accelerating problem-solving capacities of sub-national public health professionals: an evaluation of a digital immunization training intervention. BMC Health Serv Res 22, 736. https://doi.org/10.1186/s12913-022-08138-4

Critical evidence gaps in the Lancet Countdown on health and climate change

Critical evidence gaps in the Lancet Countdown on health and climate change

Global health

The 2024 report of the Lancet Countdown on health and climate change “reveals the health threats of climate change have reached record-breaking levels” and provides “the most up-to-date assessment of the links between health and climate change”.

Yet its treatment of experiential knowledge – particularly the direct observations and understanding developed by frontline health workers and communities – reveals both progress and persistent gaps in how major global health assessments value different forms of knowing.

The fundamental tension appears right at the start.

The report notes a significant challenge: “A global scarcity of internationally standardised data hinders the capacity to optimally monitor the observed health impacts of climate change and evaluate the health-protective effect of implemented interventions.”

This framing privileges standardized, quantifiable data over other forms of knowledge.

Yet paradoxically, the report recognizes that “health workers are already intimate witnesses to the impacts of climate change on the health of the communities they serve, possessing valuable knowledge that should inform both science and policy.”

This recognition of frontline experience as a valid source of knowledge is significant, even if not fully integrated into the report’s methodology.

Health workers’ experiences are not merely anecdotal but represent a crucial form of evidence gathering and early warning that conventional research methods cannot match.

When a nurse in Bangladesh notices changing patterns of heat-related illness in specific neighborhoods, or when a community health worker in Kenya observes shifts in disease transmission seasons, they are detecting signals that might take epidemiological studies decades to formally document.

Can we afford to wait?

As the report acknowledges that we face “record-breaking threats to their wellbeing, health, and survival from the rapidly changing climate,” why wait for traditional longitudinal studies to validate what health workers are already seeing?

Explore the value of health workers’ experiential knowledge: Jones, I., Mbuh, C., Sadki, R., Eller, K., Rhoda, D., 2023. On the frontline of climate change and health: A health worker eyewitness report. The Geneva Learning Foundation. https://doi.org/10.5281/zenodo.10204660

Their observations, if their significance and value were fully recognized, could provide vital early insights into emerging health threats and guide rapid, life-saving adaptations.

This is especially critical given the report’s call to alarm that climate change impacts are “increasingly claiming lives and livelihoods worldwide” and that “delays in climate change mitigation and adaptation have intensified these impacts.”

The humanitarian imperative to act quickly makes health workers’ experiential knowledge not just valuable but essential – they are the canaries in the coal mine of our climate crisis, and their insights could help bridge critical evidence gaps while more traditional research catches up.

The report’s most thoughtful engagement with alternative forms of knowledge comes in its treatment of Indigenous knowledge systems.

A panel titled “Indigenous knowledge for a healthy future” explicitly acknowledges that “Indigenous peoples maintain deep connections with the natural environment that are important for the social, livelihood, cultural, and spiritual practices that underpin their health and wellbeing.”

More importantly, it recognizes that “Indigenous knowledge has been shown to be the key to protect Indigenous health in times of health emergencies when official health systems and governments are unable to provide assistance to Indigenous communities.”

However, the report also acknowledges that “Indigenous medicine and worldviews are rarely considered within health care or health risk preparedness and response.”

This gap between recognizing the value of Indigenous knowledge and actually incorporating it into health systems and policies reflects a broader challenge.

A crucial observation comes in the report’s data discussion: available data are “rarely disaggregated by relevant groups (eg, gender, age, indigeneity, ethnicity, and socioeconomic level)” and “Indigenous knowledge is often overlooked, and Indigenous populations are seldom taken into consideration in the production and reporting of evidence and data.”

This gap in representation means that crucial experiential knowledge is systematically excluded from our understanding of climate change’s health impacts.

Perhaps most tellingly, while the report calls for “improved data” to evaluate progress on international commitments, it focuses primarily on standardized quantitative metrics rather than developing new frameworks that could better integrate experiential knowledge.

This reveals an underlying epistemological bias – while experiential knowledge is acknowledged as valuable, the report’s methodology remains firmly grounded in traditional scientific approaches.

Looking forward, truly leveraging experiential knowledge in understanding climate change’s health impacts will require more than just acknowledgment.

It will require developing new methodological frameworks that can systematically incorporate and validate different forms of knowing, while ensuring that frontline voices – whether from health workers, Indigenous communities, or other groups with direct experience – are centered rather than marginalized in our understanding of this global crisis.

For the Lancet Countdown to fully live up to its mission of tracking progress on health and climate change, future reports will need to more fundamentally rethink how they recognize, validate, and incorporate experiential knowledge.

The seeds of this transformation are present in the 2024 report.

Doing so is both necessary to improve science and consistent with The Lancet Countdown’s commitment to “operate an open and iterative process of indicator improvement, welcoming proposals for new indicators… from the world’s most vulnerable countries”.

References

Romanello, M., et al., 2024. The 2024 report of the Lancet Countdown on health and climate change: facing record-breaking threats from delayed action. The Lancet 404, 1847–1896. https://doi.org/10.1016/S0140-6736(24)01822-1

Jones, I., Mbuh, C., Sadki, R., Eller, K., Rhoda, D., 2023. On the frontline of climate change and health: A health worker eyewitness report. The Geneva Learning Foundation. https://doi.org/10.5281/zenodo.10204660

Jones, I., Mbuh, C., Sadki, R., Steed, I., 2024. Climate change and health: Health workers on climate, community, and the urgent need for action. The Geneva Learning Foundation. https://doi.org/10.5281/zenodo.11194918

Image: The Geneva Learning Foundation Collection © 2024

Strengthening primary health care in a changing climate

Strengthening primary health care in a changing climate

and Global health

A new article by Andy Haines, Elizabeth Wambui Kimani-Murage, and Anya Gopfert, “Strengthening primary health care in a changing climate,” outlines how climate change is already impacting health systems worldwide, with primary health care (PHC) workers bearing the immediate burden of response.

Haines and colleagues make a compelling case for strengthening primary health care (PHC) as a cornerstone of climate-resilient health systems.

First, they note that approximately 90% of essential universal health coverage interventions are delivered through PHC settings, making these facilities and workers the backbone of healthcare delivery.

This is particularly significant because PHC systems address many of the health outcomes most affected by climate change, including non-communicable diseases, childhood undernutrition, and common infectious diseases like malaria, diarrheal diseases, and respiratory infections.

Furthermore, PHC workers are often the first responders to extreme weather events such as floods, droughts, and heatwaves.

They must manage both the immediate health impacts and the longer-term consequences of these events.

This comprehensive view of PHC’s role in climate resilience represents a significant shift from viewing primary care merely as a service delivery mechanism to recognizing it as a crucial component of climate adaptation and health system strengthening.

The authors argue that investing in PHC is not only essential for addressing immediate health needs but also for building long-term resilience to climate-related health threats.

In examining workforce issues, Haines et al. specifically emphasize that “building the capacity of the PHC and public health workforce in emergency preparedness and response to climate-induced risks is crucial for enhancing the resilience of health systems.”

They argue that “the health-care workforce, including multidisciplinary PHC teams, should be provided with training and education on the impacts of climate change on health and the implications for health-care delivery.”

The article specifies that this training should focus on three key areas: “strengthening integrated disease surveillance and response systems,” “diagnosis and management of changing disease patterns (eg, outbreaks of vector-borne diseases in new locations),” and “interpretation and use of available climate, weather, and health data to support planning and management of adaptation and mitigation interventions.”

They mention resources like those proposed by the “WONCA Global Family Doctor Planetary Health Working Party” as instructive for such training.

Although the article emphasizes the role of PHC workers as being “often on the front line of responses to extreme events such as floods, droughts, and heatwaves,” it does not discuss mechanisms for capturing or leveraging their experiential knowledge.

This is what they know because they are there every day.

Recommendations follow a traditional institutional approach: strengthen health information systems, build workforce capacity, develop integrated service delivery models, increase funding, and enhance governance.

While these recommendations are well-founded, they primarily envision a top-down flow of knowledge and resources, with health workers positioned as recipients of training and implementers of policies.

The epistemological framework underlying their recommendations reflects what educational theorists would recognize as a transmission model of learning, where knowledge is conceived as flowing primarily from experts to practitioners in a hierarchical manner.

This approach, while valuable for disseminating standardized protocols and evidence-based practices, implicitly positions health workers as passive recipients rather than active knowledge creators and agents of climate-health resilience.

Such a framework potentially undervalues the situated knowledge and practical wisdom (what Aristotle called phronesis) that practitioners develop through direct experience with climate-health challenges in their communities.

It also overlooks the potential for what complexity theorists describe as emergent learning – where new knowledge and practices arise from the dynamic interactions between practitioners facing similar challenges in different contexts.

Our research has documented how health workers are already responding to climate-related health challenges.

For example, observations from more than 1,200 health workers in 68 countries reveal a rich tapestry of local knowledge and insights that often go unrecognized in formal academic and policy discussions

Health workers are already intimate witnesses to the impacts of climate change on the health of the communities they serve, possessing valuable knowledge that should inform both science and policy.

Where Haines sees health workers primarily as implementers of climate-resilient healthcare strategies, we view them as leaders and innovators in climate adaptation.

However, these perspectives need not be mutually exclusive.

TGLF’s model offers a bridge between formal institutional approaches and ground-level experiential knowledge.

New peer learning platforms like Teach to Reach enable rapid sharing of solutions across geographical and institutional boundaries.

This platform enables health workers to be both learners and teachers, sharing successful adaptations while learning from colleagues facing similar challenges in different contexts.

Such participatory approaches also help local knowledge inform global understanding – if global research institutions and funders are willing to listen and learn.

When TGLF gathered observations about climate change impacts on health, we received detailed accounts of everything from disease transmission to healthcare access.

A health worker from Cameroon described how flooding from Mount Cameroon led to deaths in their community.

Another from Kenya shared how changing agricultural patterns forced them to develop new strategies for ensuring safe food access.

Jones, I., Mbuh, C., Sadki, R., Eller, K., Rhoda, D., 2023. On the frontline of climate change and health: A health worker eyewitness report. The Geneva Learning Foundation. https://doi.org/10.5281/zenodo.10204660

These granular insights complement the broader statistical evidence presented in academic literature, providing crucial context for how climate changes manifest in specific communities.

TGLF’s model demonstrates how digital technologies can democratize knowledge sharing to strengthen scientific evidence and drive locally-led action.

This creates a dynamic knowledge ecosystem that can respond more quickly to emerging challenges than traditional top-down approaches.

Importantly, this model addresses a key gap in Haines’ recommendations: the need for rapid, scalable knowledge sharing among frontline workers.

While formal research and policy development necessarily take time, climate impacts are already affecting communities.

TGLF’s approach enables immediate peer learning while building an evidence base for longer-term policy development.

The model also addresses the issue of trust.

Health workers, as trusted community members, play a crucial role in helping communities make sense of and navigate the changes they are facing.

Their understanding of local contexts and constraints are critical to develop strategies that can actually be implemented.

By combining institutional support with health worker-led local action, we can strengthen health systems to be both technically robust and locally responsive.

Our experience at the Geneva Learning Foundation suggests that new learning and leadership are needed to bridge these approaches, enabling the rapid sharing of both formal and experiential knowledge while building the collective capacity needed to survive the impacts of climate change on our health.

References

Haines, A., Kimani-Murage, E.W., Gopfert, A., 2024. Strengthening primary health care in a changing climate. The Lancet 404, 1620–1622. https://doi.org/10.1016/S0140-6736(24)02193-7

Image: The Geneva Learning Foundation Collection © 2024

Anecdote or lived experience reimagining knowledge for climate-resilient health systems

Anecdote or lived experience: reimagining knowledge for climate-resilient health systems

Global health

A health worker in rural Kenya notices that malaria cases are appearing earlier in the season than usual.

A nurse in Bangladesh observes that certain neighborhoods are experiencing more heat-related illnesses despite similar temperatures.

These observations often remain trapped in the realm of “anecdotal evidence.” 

The dominant epistemological framework in public health traditionally dismisses such knowledge as unreliable, subjective, and of limited scientific value.

This dismissal stems from a deeply-rooted global health paradigm that privileges quantitative data, randomized controlled trials, and statistical significance over the nuanced, contextual understanding that emerges from direct experience.

The phrase “it’s just anecdotal” has become a subtle but powerful way of delegitimizing knowledge that does not conform to established scientific methodologies.

Yet this epistemological stance creates a significant blind spot in our understanding of how climate change affects health at the community level.

Climate change manifests in complex, locally specific ways that often elude traditional epidemiological surveillance systems.

The health worker who notices shifting disease patterns or the community nurse who identifies vulnerable populations possesses what philosopher Donald Schön termed “knowing-in-action” – a form of knowledge that emerges from sustained engagement with complex, dynamic situations.

Experiential knowledge often precedes formal scientific understanding, particularly in the context of climate change where impacts are emerging and evolving rapidly.

Health workers’ observations are not mere anecdotes but rather early warning signals of climate-health relationships that would take years to document through traditional research methods.

Why would we build early warning systems that ignore the significance or value of health worker observations and insights?

Is the risk of error greater than the risk of inaction?

In late 2023, more than 1 million people were displaced by flooding from intense rainfall in parts of Somalia, Kenya, and Ethiopia, attributed to a combination of climate change and the Indian Ocean Dipole, a natural climate phenomenon.

Are there signals that health workers might be attuned to, alongside weather systems to measure them?

The challenge, then, is not to replace scientific methodologies but to develop new epistemological frameworks that can integrate different forms of knowing.

This requires recognizing that knowledge exists on a spectrum rather than in hierarchical tiers.

Experiential knowledge, systematic observation, statistical analysis, and randomized controlled trials each offer different and complementary insights into complex climate-health relationships.

A new epistemological framework would recognize that the health worker who notices changing disease patterns is engaging in what anthropologist James Scott calls “mētis” – a form of practical knowledge that comes from intimate familiarity with local conditions.

Is this knowledge necessarily less valuable than statistical data or no data?

It is different and often provides crucial context that helps interpret quantitative findings.

Let us imagine how this integration might work in practice.

In the Philippines, a climate-health surveillance system could combine traditional epidemiological data with structured documentation of health workers’ observations.

Health workers would use a mobile app to share unusual patterns or emerging concerns with each other.

This could then be analyzed alongside conventional surveillance data.

Such an approach could identify climate-health relationships that are not visible through standard surveillance alone.

Health workers can also form “knowledge circles” in which they regularly meet to share observations and insights about climate-related health impacts.

These observations can then be systematically documented and analyzed, creating a bridge between experiential knowledge and formal evidence bases.

When patterns emerge across multiple knowledge circles, they trigger more formal investigation.

This shift requires rethinking how we validate knowledge.

Instead of asking whether an observation is “merely anecdotal,” we might ask: What does this observation tell us about local conditions? How does it complement our quantitative data? What patterns emerge when we more systematically collect and analyze experiential knowledge?

The implications of this epistemological shift extend beyond climate change.

By recognizing the value of experiential knowledge, health systems will become more adaptive and responsive to emerging challenges.

Health workers, feeling their knowledge is valued, become more engaged in systematic observation and documentation.

Communities, seeing their experiences reflected in health system responses, develop greater trust in health institutions.

However, this shift faces significant challenges.

Academic institutions, funding bodies, and policy makers often remain wedded to traditional hierarchies of evidence.

Publishing systems privilege certain types of knowledge over others.

Career advancement often depends on producing conventional scientific evidence rather than integrating different forms of knowing.

Overcoming these challenges requires institutional change.

Medical and public health education needs to incorporate training in recognizing and documenting experiential knowledge.

Research methodologies need to expand to include systematic ways of collecting and analyzing practical knowledge.

Funding mechanisms need to support projects that bridge different epistemological approaches.

The climate crisis demands this evolution in how we think about knowledge.

As health systems face unprecedented challenges, we cannot afford to ignore any source of understanding about how climate change affects human health.

The health worker’s observation, the community’s experience, and the statistician’s analysis all have crucial roles to play in building climate-resilient health systems.

This is not about replacing scientific rigor but about expanding our understanding of what constitutes valid knowledge.

By creating frameworks that can integrate different forms of knowing, we strengthen our ability to respond effectively to the complex challenges posed by climate change.

The future of climate-resilient health systems depends not just on what we know, but on how we think about knowing itself.

References

Haines, A., Kimani-Murage, E.W., Gopfert, A., 2024. Strengthening primary health care in a changing climate. The Lancet 404, 1620–1622. https://doi.org/10.1016/S0140-6736(24)02193-7

Jones, I., Mbuh, C., Sadki, R., Eller, K., Rhoda, D., 2023. On the frontline of climate change and health: A health worker eyewitness report. The Geneva Learning Foundation. https://doi.org/10.5281/ZENODO.10204660

Jones, I., Mbuh, C., Sadki, R., Steed, I., 2024. Climate change and health: Health workers on climate, community, and the urgent need for action. The Geneva Learning Foundation. https://doi.org/10.5281/ZENODO.11194918

Romanello, M., et al. The 2024 report of the Lancet Countdown on health and climate change: facing record-breaking threats from delayed action. The Lancet 404, 1847–1896. https://doi.org/10.1016/S0140-6736(24)01822-1

Schön, D.A., 1995. Knowing-in-action: The new scholarship requires a new epistemology. Change: The Magazine of Higher Learning 27, 27–34.

Scott, J.C., 2020. Seeing like a state: how certain schemes to improve the human condition have failed. ed, Yale agrarian studies. Yale University Press, New Haven, CT London.

Teach to Reach network of organizational leaders

Teach to Reach’s new leadership network connects health organizations tackling common challenges

Global health

The Geneva Learning Foundation is launching REACH (Relate, Engage, Act, Connect, Help), a new initiative to connect leaders of health organizations who are solving similar problems in different countries.

Launching November 6, 2024 REACH responds to an unexpected outcome of Teach to Reach, a peer learning platform that–in less than four years–has already documented over 10,000 local solutions and experiences to health challenges by connecting more than 60,000 participants across 77 countries.

When organizations began formally participating in Teach to Reach in June 2024, many leaders discovered they were tackling similar challenges.

A digital immunization tracking system in Rwanda sparked interest from several African countries.

A community engagement approach to vaccine hesitancy in Nigeria resonated with teams in Kenya and Zimbabwe.

These spontaneous connections led to the creation of REACH.

What is Teach to Reach?

“Teach to Reach is a place where you learn in the most formidable way. You’re learning from people’s experiences and it makes the learning very easy to adapt, very easy to replicate wherever you are,” says Ful Marine Fuen, Humanitarian Program Coordinator at Cameroon Baptist Convention Health Services.

Teach to Reach is a bilingual (French/English) peer learning platform where government health workers, local organizations, and frontline staff document, analyze, and share implementation solutions across borders.

Half of all participants work in government health services, with around 80% based at district and facility levels where policy meets practice.

The platform’s structured learning process includes pre-event experience sharing, live sessions for discussion and networking, and post-event analysis to capture insights.

“It’s a meeting of giving and receiving. Because with Teach to Reach, we always learn from peers and we develop ourselves and develop others,” notes Arthur Fidelis Metsampito Bamlatol, Coordinator at AAPSEB Cameroon.

From individual learning to organizational impact

The impact of these connections is already visible.

Nduka Ozor, Project Director at the Centre for HIV/AIDS and STD RESEARCH in Nigeria, describes how a single connection expanded his organization’s reach: “I was able to meet with a potential partner who stays in Australia. Something I thought is just an online stuff is moving into a greater partnership. We have had several meetings with other networks from that initial meeting, including with representatives of New York University.”

These kinds of partnerships form naturally as organizations share their work.

Imagine what else might happen as health leaders like these meet, connect, and learn:

  • In Rwanda, Albert Ndagijimana shared how his country achieved 95% childhood vaccination coverage through initiatives like digital tracking of immunization outreach
  • In Kenya, Samuel Mutambuki‘s organization works with other civil society groups to rehabilitate areas affected by illegal dumping and create community gardens
  • In Zimbabwe, Rebecca Chirenga’s team addresses how climate change and food insecurity are driving early marriage and teenage pregnancy, with half of girls dropping out before completing secondary school

“It is essentially a framework that allows us to share experiences… to strengthen our capacities,” says Patrice Kazadi, Project Director at Save the Children International DR Congo. “The challenges in DRC can be the same as in Ivory Coast and what is done in Ivory Coast can also help address challenges in DRC.”

REACH: A new network exclusively for Teach to Reach Partners

REACH builds on this foundation but with an important distinction – it’s exclusively for leaders of organizations that have committed to partnership with Teach to Reach.

Over 700 organizational leaders have already confirmed their participation, representing both government agencies and civil society organizations.

The first REACH sessions will:

  1. Connect organizations working on similar challenges
  2. Share practical approaches that have worked in different contexts
  3. Facilitate direct conversations between organizational leaders
  4. Identify potential areas for collaboration

How can organizations join REACH?

To participate in REACH, organizations must complete all partnership steps for Teach to Reach:

  1. Attend a Partner briefing
  2. Complete the Partnership application
  3. Share the Teach to Reach announcement
  4. Have organizational leadership endorse participation