Why lack of continuous learning is the Achilles heel of immunization

Why lack of continuous learning is the Achilles heel of immunization 

Reda SadkiGlobal health, Theory

Continuous learning is lacking in immunization.

This lack may be an underestimated barrier to the “Big Catch-Up” and reaching zero-dose children

This was a key finding presented at Gavi’s Zero-Dose Learning Hub (ZDLH) webinar “Equity in Action: Local Strategies for Reaching Zero-Dose Children and Communities” on 24 January 2024.

The finding is based on analysis large-scale measurements conducted by the Geneva Learning Foundation in 2020 and 2022, with more than 10,000 immunization staff from all levels of the health system, job categories, and contexts, responding from over 90 countries.

YearnContinuous learningDialogue & InquiryTeam learningEmbedded SystemsEmpowered PeopleSystem ConnectionStrategic Leadership
TGLF global measurements (2020 and 2022) of learning culture in immunization, using the Dimensions of Learning Organization Questionnaire (DLOQ)

What does this finding actually mean?

In immunization, the following gaps in continuous learning are likely to be hindering performance.

  1. Relatively few learning opportunities for immunization staff
  2. Limitations on the ability for staff to experiment and take risks 
  3. Low tolerance for failure when trying something new
  4. A focus on completing immunization tasks rather than developing skills and future capacity
  5. Lack of encouragement for on-the-job learning 

This gap hurts more than ever when adapting strategies to reach “zero-dose” children.

These are children who have not been reached when immunization staff carry out what they usually do.

The traditional learning model is one in which knowledge is codified into lengthy guidelines that are then expected to trickle down from the national team to the local levels, with local staff competencies focused on following instructions, not learning, experimenting, or preparing for the future.

For many immunization staff, this is the reference model that has helped eradicate polio, for example, and to achieve impressive gains that have saved millions of children’s lives.

It can therefore be difficult to understand why closing persistent equity gaps and getting life-saving vaccines to every child would now require transforming this model.

Yet, there is growing evidence that peer learning and experience sharing between health workers does help surface creative, context-specific solutions tailored to the barriers faced by under-immunized communities. 

Such learning can be embedded into work, unlike formal training that requires staff to stop work (reducing performance to zero) in order to learn.

Yet the predominant culture does little to motivate or empower these workers to recognize or reward such work-based learning.

Furthermore, without opportunities to develop skills, try new approaches, and learn from both successes and failures, staff may become demotivated and ineffective. 

This is not an argument to invest in formal training.

Investment in formal training has failed to measurably translate into improved immunization performance.

Worse, the per diem economy of extrinsic incentives for formal training has, in some places, led to absurdity: some health workers may earn more by sitting in classrooms than from doing their work.

With a weak culture of learning, the system likely misses out on practices that make a difference.

This is the “how” that bridges the gap between best practice and what it takes to apply it in a specific context.

The same evidence also demonstrates a consistently-strong correlation between strengthened continuous learning and performance.

Investment in continuous learning is simple, costs surprisingly little given its scalability and effectiveness.

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

How does the scalability of peer learning compare to expert-led coaching ‘fellowships’?

That means investment in continuous learning is already proven to result in improved performance.

We call this “learning-based work”.


Watkins, K.E. and Marsick, V.J., 2023. Chapter 4. Learning informally at work: Reframing learning and development. In Rethinking Workplace Learning and Development. Edward Elgar Publishing. Excerpt: https://redasadki.me/2023/11/04/how-we-reframed-learning-and-development-learning-based-complex-work/

The Geneva Learning Foundation. From exchange to action: Summary report of Gavi Zero-Dose Learning Hub inter-country exchanges. Geneva: The Geneva Learning Foundation, 2023. https://doi.org/10.5281/zenodo.10132961

The Geneva Learning Foundation. Motivation, Learning Culture and Immunization Programme Performance: Practitioner Perspectives (IA2030 Case Study 7) (1.0); Geneva: The Geneva Learning Foundation, 2022. https://doi.org/10.5281/zenodo.7004304

Image: The Geneva Learning Foundation Collection © 2024