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

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

Reda SadkiGlobal health, Theory

A formula for calculating learning efficacy, (E), considering the importance of each criterion and the specific ratings for peer learning, is:

\text{Efficacy} = \frac{S \cdot w_S + I \cdot w_I + C \cdot w_C + F \cdot w_F + U \cdot w_U}{w_S + w_I + w_C + w_F + w_U}

This abstract formula provides a way to quantify learning efficacy, considering various educational criteria and their relative importance (weights) for effective learning.

Variable DefinitionDescription 
SScalabilityAbility to accommodate a large number of learners 
IInformation fidelityQuality and reliability of information 
CCost effectivenessFinancial efficiency of the learning method 
FFeedback qualityQuality of feedback received 
UUniformityConsistency of learning experience 
Summary of five variables that contribute to learning efficacy

Weights for each variables are derived from empirical data and expert consensus.

All values are on a scale of 0-4, with a “4” representing the highest level.

ScalabilityInformation fidelityCost-benefitFeedback qualityUniformity
w_Sw_Iw_Cw_Fw_U
4.003.004.003.001.00
Assigned weights

Here is a summary table including all values for each criterion, learning efficacy calculated with weights, and Efficacy-Scale Score (ESS) for peer learning, cascade training, and expert coaching.

The Efficacy-Scale Score (ESS) can be calculated by multiplying the efficacy (E) of a learning method by the number of learners (N).

\text{ESS} = E \times N

This table provides a detailed comparison of the values for each criterion across the different learning methods, the calculated learning efficacy values considering the specified weights, and the Efficacy-Scale Score (ESS) for each method.

Type of learningScalabilityInformation fidelityCost effectivenessFeedback qualityUniformityLearning efficacy# of learnersEfficacy-Scale Score
Peer learning4.002.504.002.501.003.2010003200
Cascade training2.001.002.000.500.501.40500700
Expert coaching0.504.001.004.003.002.2060132

Of course, there are many nuances in individual programmes that could affect the real-world effectiveness of this simple model. The model, grounded in empirical data and simplified to highlight core determinants of learning efficacy, leverages statistical weighting to prioritize key educational factors, acknowledging its abstraction from the multifaceted nature of educational effectiveness and assumptions may not capture all nuances of individual learning scenarios.

Peer learning

The calculated learning efficacy for peer learning, (E_{\text {peer}}) , is 3.20. This value reflects the weighted assessment of peer learning’s strengths and characteristics according to the provided criteria and their importance.

By virtue of scalability, ESS for peer learning is 24 times higher than expert coaching.

Cascade training

For Cascade Training, the calculated learning efficacy, (E_{\text {cascade}}), is approximately 1.40. This reflects the weighted assessment based on the provided criteria and their importance, indicating lower efficacy compared to peer learning.

Cascade training has a higher ESS than expert coaching, due to its ability to achieve scale.

Learn more: Why does cascade training fail?

Expert coaching

For Expert Coaching, the calculated learning efficacy, (E_{\text {expert}}), is approximately 2.20. This value indicates higher efficacy than cascade training but lower than peer learning.

However, the ESS is the lowest of the three methods, primarily due to its inability to scale. Read this article for a scalability comparison between expert coaching and peer learning.

Image: The Geneva Learning Foundation Collection © 2024

Why does cascade training fail

Why does cascade training fail?

Reda SadkiGlobal health, Theory

Cascade training remains widely used in global health.

Cascade training can look great on paper: an expert trains a small group who, in turn, train others, thereby theoretically scaling the knowledge across an organization.

It attempts to combine the advantages of expert coaching and peer learning by passing knowledge down a hierarchy.

However, despite its promise and persistent use, cascade training is plagued by several factors that often lead to its failure.

This is well-documented in the field of learning, but largely unknown (or ignored) in global health.

What are the mechanics of this known inefficacy?

Here are four factors that contribute to the failure of cascade training

1. Information loss

Consider a model where an expert holds a knowledge set K. In each subsequent layer of the cascade, α percentage of the knowledge is lost:

K_n = K \cdot \alpha^n

  • Where K_n is the knowledge at the nth level of the cascade. As n grows, K_n exponentially decreases, leading to severe information loss.
  • Each layer in the cascade introduces a potential for misunderstanding the original information, leading to the training equivalent of the ‘telephone game’.

2. Lack of feedback

In a cascade model, only the first layer receives feedback from an actual expert.

  • Subsequent layers have to rely on their immediate ‘trainers,’ who might not have the expertise to correct nuanced mistakes.
  • The hierarchical relationship between trainer and trainee is different from peer learning, in which it is assumed that everyone has something to learn from others, and expertise is produced through collaborative learning.

3. Skill variation

  • Not everyone is equipped to teach others.
  • The people who receive the training first are not necessarily the best at conveying it to the next layer, leading to unequal training quality.

4. Dilution of responsibility

  • As the cascade flows down, the sense of responsibility for the quality and fidelity of the training dilutes.
  • The absence of feedback to drive a quality development process exacerbates this.

Image: The Geneva Learning Foundation Collection © 2024

The capability trap

The capability trap: Nobody ever gets credit for fixing problems that never happened

Reda SadkiLeadership, Learning strategy

Here is a summary of the key points about the capability trap, from the article “Nobody ever gets credit for fixing problems that never happened: creating and sustaining process improvement”.

What is the capability trap?

  • Many companies invest heavily in process improvement programs, yet few efforts actually produce significant results. This is called the “improvement paradox”.
  • The problem lies not with the specific tools, but rather how the introduction of new programs interacts with existing organizational structures and dynamics.
  • Using system dynamics modeling, the authors studied implementation challenges in depth through over a dozen case studies. Their models reveal insights into why improvement programs often fail.

Core causal loops

  • The “Work Harder” loop – managers pressure people to spend more time working to immediately boost throughput and close performance gaps. But this is only temporary.
  • The “Work Smarter” loop – managers encourage improvement activities which enhance process capability over time for more enduring gains, but there is a delay before benefits are seen.
  • The “Reinvestment” reinforcing loop – successfully improving capability frees up more time for further improvement. But the reverse vicious cycle often dominates instead.
  • The “Shortcuts” loop – facing pressure, people cut corners on improvement activities which temporarily frees up more time for work. But this gradually erodes capability.

The capability trap

  • Short-term “Work Harder” and “Shortcuts” decisions eventually hurt capability and require heroic work efforts to maintain performance, creating a downward spiral.
  • However, because capability erodes slowly, managers fail to connect problems to past decisions and blame poor worker motivation instead, leading to a self-confirming cycle.
  • Even improvement programs just increase pressure and drive more shortcuts, making stereotypes and conflicts worse. This “capability trap” causes programs to fail.

The “capability trap” refers to the downward spiral organizations can get caught in, where attempting to boost performance by pressuring people to “work harder” actually erodes process capability over time. This trap works through a few key mechanisms:

  1. Facing pressure, people cut corners and reduce time spent on improvement activities in order to free up more time for immediate work. This temporarily boosts throughput.
  2. However, this comes at a cost of gradually declining process capability, as less time is invested in maintenance, training, and problem solving.
  3. Capability erosion then reduces performance, widening the gap versus desired performance levels.
  4. Managers falsely attribute this to poor motivation or effort from the workforce. They lack awareness of the capability trap dynamics, and the delays between pressing people to “work harder” and the capability declines that eventually ensue.
  5. Management increases pressure further, demanding heroic work efforts, which causes workers to cut even more corners. This spirals capability downward while confirming management’s incorrect attribution even more.

Key takeaway for learning leaders

Learning leaders must understand the systemic traps identified in the article that underly failed improvement initiatives and facilitate mental model shifts. This help build sustainable, effective learning programs to be realized through productive capability-enhancing cycles.

Key takeaway for immunization leaders

It is reasonable to hypothesize that poor health worker performance is a symptom rather than the cause of poor immunization programme performance. Short-term decisions, often responding to top-down targets and donor requirements, hurt capability and require, as the authors say, “heroic work efforts to maintain performance, creating a downward spiral.” Managers then incorrectly diagnose this as a performance problem due to motivation.

How to escape the capability trap

The key to avoiding or escaping this trap is therefore shifting the mental models that reinforce the incorrect attributions about motivation. Some ways to do this include:

  • Educating managers on the systemic structures causing the capability trap through methods like system dynamics modeling
  • Allowing time for capability-enhancing improvements to take effect before judging performance
  • Incentivizing quality and sustainability of throughput rather than just short-term volume alone
  • Seeking input from workers on the barriers to improvement they face

With awareness of the structural causes and delays, managers can avoid erroneously attributing blame. Patience and a systems perspective are critical for companies to invest their way out of the capability trap.

  • Shift mental models to recognize system structures leading to the capability trap, rather than blaming people. Then improvement tools can work.
  • A useful example could be system dynamics workshops that achieved this shift and enabled successful programs, dramatically enhancing performance.

Reference

Repenning, N.P., Sterman, J.D., 2001. Nobody ever gets credit for fixing problems that never happened: creating and sustaining process improvement. California management review 43, 64–88. https://doi.org/10.2307/41166101

Illustration: The Geneva Learning Foundation Collection © 2024

Gender analysis of the World Health Organization online learning program on Immunization Agenda 2030

Gender analysis of the World Health Organization online learning program on Immunization Agenda 2030

Reda SadkiGlobal health

The article “Gender analysis of the World Health Organization online learning program on Immunization Agenda 2030” is, according to the authors, “the first to showcase the positive inclusion of mainstreaming gender in a WHO capacity-building program.”

Context:

  • The paper analyzes action plans developed and peer reviewed by participants in one cohort of the 2021 World Health Organization (WHO) Scholar Level 1 certification course on Immunization Agenda 2030 (IA2030), a course developed by The Geneva Learning Foundation (TGLF) with funding from the Bill & Melinda Gates Foundation (BMGF).
  • WHO’s Scholar courses only utilize the knowledge creation component of TGLF’s learning-to-action model, whereas the full model supports implementation that leads to improved health outcomes.
  • TGLF uses an innovative peer learning-to-action model, developed through over a decade of research and practice, focused on knowledge creation through dialogue, critique, and collaboration, with rubric-based peer feedback scaffolding the learning process.
  • The course was facilitated by Charlotte Mbuh and Min Zha, two women learning leaders at The Geneva Learning Foundation (TGLF), who combine deep expertise in learning science and real-world knowledge of immunization in low- and middle-income countries (LMICs).

Key findings:

  • The analysis included 111 action plans, a subset of the projects and insights shared, from participants across 31 countries working to improve immunization programs.
  • It found that “all action plans in the 111 sample, except three, included gender considerations” showing the course was effective in raising awareness of gender barriers.

This is consistent with the known effectiveness of peer feedback, as the rubric followed by each learner included specific instructions to “describe how your action plan has considered and integrated gender dimensions in immunization.”

TGLF’s peer learning model focuses on generating and applying new knowledge. This appears to be conducive to raising awareness of issues like gender barriers to immunization. By giving and receiving feedback, participants build understanding.

Whereas only around ten percent of learners participated in expert-led presentations offered about gender and immunization, every learner had to think through and write up gender analysis. And every learner had to give feedback on the gender analyses of three colleagues.

The social nature of giving and received structured peer feedback, supported by expert-designed resources, creates accountability and motivation for integrating gender considerations. Participants educate one another on blindspots, helping embed attention to gender issues.

Compared to traditional expert-led capacity building, this peer-led approach empowered participants to learn from each other’s experience, situating gender in their real-world practice, rather than as an abstract concept that requires global experts to explain it. This participant-driven process with built-in feedback mechanisms is likely to have helped make the increased gender awareness actionable.

Gender analysis: what we learned about gender barriers

  • The most cited barrier was “low education and health literacy” affecting immunization uptake. As one plan stated, “lower educational levels of maternal caregivers are more commonly related to under-vaccination”.
  • Other major barriers were difficulties accessing services due to “gender-related factors influencing mobility, location, availability, or quality of health services” and lack of male involvement in decisions, as “men make most of the household decisions while they often do not have sufficient information”.
  • Proposed strategies focused on areas like “incentive schemes” and “on-the-job support” for female health workers, “community engagement” to improve literacy, and better “engagement of men” in immunization activities.

TGLF’s peer learning approach likely contributed to raising awareness of gender issues and ability to propose context-specific solutions, though some implicit biases may have affected peer evaluations.

Overall, the analysis shows mainstreaming gender was an effective part of this capacity building program, and the authors appear convinced of its potential to lead to more gender-equitable and effective immunization policies and services.

However, the authors’ claim that “gender inequality and harmful gender norms in many settings create barriers and are the main reasons for suboptimal immunization coverage” is not substantiated by the available data. The action plans do provide some contextual descriptions of gender barriers and describe an intent to take action. But descriptions shared by learners were not verified, and the course did not offer any support to learners in implementing their proposed actions.

Reference

Nyasulu, B.J., Heidari, S., Manna, M., Bahl, J., Goodman, T., 2023. Gender analysis of the World Health Organization online learning program on Immunization Agenda 2030. Frontiers in Global Women’s Health 4, 1230109. https://doi.org/10.3389/fgwh.2023.1230109

Illustration: The Geneva Learning Foundation Collection © 2024

Towards reimagined technical assistance Thinking beyond the current policy options

Towards reimagined technical assistance: thinking beyond the current policy options

Reda SadkiGlobal health, Leadership

In the article “Towards reimagined technical assistance: the current policy options and opportunities for change”, Alexandra Nastase and her colleagues argues that technical assistance should be framed as a policy option for governments. It outlines different models of technical assistance:

  1. Capacity substitution: Technical advisers perform government functions due to urgent needs or lack of in-house expertise. This can fill gaps but has “clear limitations in building state capability.”
  2. Capacity supplementation: Technical advisers provide specific expertise to complement government efforts in challenging areas. This can “fill essential gaps at critical moments” but has limitations for building sustainable capacity.  
  3. Capacity development: Technical advisers play a facilitator role focused on enabling change and strengthening government capacity over the long term. This takes time but “there is a higher chance that these [results] will be sustainable.”

Governments may choose from this spectrum of roles for technical advisers in designing assistance programs based on the objectives, limitations, and tradeoffs involved with each approach: “The most common fallacy is to expect every type of technical assistance to lead to capacity development. We do not believe that is the case. Suppose governments choose to use externals to do the work and replace government functions. In that case, it is not realistic to expect that it will build a capability to do the work independently of consultants.”

Furthermore, technical assistance should be designed through “meaningful and equal dialogue between governments and funders” to ensure it focuses on core issues and builds sustainable capacity. Considerations that need to be highlighted include balancing short-term needs with long-term capacity building and shifting power to local experts.

However, this requires reframing technical assistance as a policy option through transparent dialogue between government and funders.

What key assumptions about technical assistance does this challenge?

The article challenges some key assumptions and orthodox views about technical assistance in global health:

  1. It frames technical assistance not as aid provided by donors, but as a policy option and domestic choice that governments make to meet their objectives. This contrasts with the common donor-centric view.
  2. It critiques the assumption that all technical assistance inherently builds sustainable government capacity and questions this expected linear relationship. The article argues different types of technical assistance have fundamentally different aims – gap-filling versus long-term capacity building.
  3. The article challenges the idealistic principles often promoted for technical assistance, like localization, government ownership, and adaptability. It suggests the evidence is lacking on if these principles effectively lead to better development outcomes on the ground.  
  4. The article argues that technical assistance decisions involve real dilemmas, tradeoffs and tensions in practice rather than being clear cut. It challenges the notion of win-win solutions and highlights risks like unintended consequences.
  5. By outlining limitations of different technical assistance approaches, the article pushes back against a one-size-fits-all mindset. The appropriate approach depends on contextual factors and clarity of purpose.
  6. The article questions typical measures of success for technical assistance based on fast results and output delivery. It advocates for greater focus on processes that enable long-term capacity development even if slower.

How does The Geneva Learning Foundation’s work fit into such a model?

At The Geneva Learning Foundation (TGLF), we realized that our own model to support locally-led leadership to drive change could be described as a new type of technical assistance that does not fit into any of the existing three categories, because:

  1. TGLF’s model is grounded in principles of localization and decolonization that shift power dynamics by empowering government health workers from all levels of the health system – not only the national authorities – to recognize what change is needed, to lead this change where they work. We have observed that, even in fragile contexts, this accelerates progress toward country goals, and strengthens or can help rebuild civil society fabric.
  2. It focuses on nurturing intrinsic motivation and peer accountability rather than imposing top-down directives or extrinsic incentives. 
  3. It utilizes lateral feedback loops and informal, self-organized networks that cut across hierarchies and geographic boundaries.
  4. It emphasizes flexibility, adaptation to local contexts, and problem-driven iteration rather than pre-defined solutions.
  5. It builds sustainable capacity and self-organized learning cultures that reduce dependency on external support.

Reference: Nastase, A., Rajan, A., French, B., Bhattacharya, D., 2020. Towards reimagined technical assistance: the current policy options and opportunities for change. Gates Open Res 4, 180. https://doi.org/10.12688/gatesopenres.13204.1

Illustration: The Geneva Learning Foundation Collection © 2024

Protect Invest Together

Protect, invest, together: strengthening health workforce through new learning models

Reda SadkiGlobal health

In “Prioritising the health and care workforce shortage: protect, invest, together,” Agyeman-Manu et al. assert that the COVID-19 pandemic aggravated longstanding health workforce deficiencies globally, especially in under-resourced nations. 

With projected shortages of 10 million health workers concentrated in Africa and the Middle East by 2030, the authors urgently call for policymakers to commit to retaining and expanding national health workforces. 

They propose common-sense solutions: increased, coordinated financing and collaboration across government agencies managing health, finance, economic development, education and labor portfolios.

But how can such interconnected, long-term investments be designed for maximum sustainable impact?

And what is the role of education?

Rethinking health worker learning

In a 2021 WHO survey across 159 countries, most health workers reported lacking adequate training to respond effectively to pandemic demands. This exposed systemic weaknesses in how health workforces develop skills at scale. Long before the COVID-19 pandemic, limitations of traditional learning approaches were already obvious.

Prevailing modalities overly rely on passive knowledge transfer rather than active learner empowerment and engagement with real-world complexities. While assessment and credentialing are important, ultimately learning must be judged by its relevance, application and impact on people’s lives and health systems.

Between April and June 2020, I had the privilege of working with a group of 600 of Scholars of The Geneva Learning Foundation (TGLF) from 86 countries. Together, we designed an immersive learning cycle integrating skill-building and peer exchange for those on the frontlines of the epidemic. We called it the “COVID-19 Peer Hub”. 

It grew into an ecosystem that connected over 6,000 health professionals across 86 countries to share unfiltered insights, give voice to on-the-ground needs, and turn shared experience into action.

Within three months, a third of participants had already implemented COVID-19 recovery plans, citing peer support as the main driver for turning their commitment into results.

By the end of 2020, TGLF’s immunization platform, network, and community had tripled in size.

In 2022, this network transformed into a Movement for Immunization Agenda 2030 (IA2030).

Informing health workforce decisions

What insights can health workforce policymakers draw from the Geneva Learning Foundation’s unique work to achieve the ambitious growth and support targets outlined by Agyeman-Manu et al.?

First, expert-driven, top-down  approaches alone cannot handle emergent real-world complexities. In TGLF’s learning cycles, the most significant learning often occurs in lateral, one-to-one networking meetings between peers. These defy boundaries of geography, gender, ethnicity, religion, and job roles.

Second, thoughtfully-applied technology can exponentially accelerate learning’s reach, access and connections following learner needs. New digital modalities opened by pandemic disruptions must be sustained and optimized post-crisis, despite the tendency to revert back to previous norms of learning through high-cost, low-volume formal trainings and workshop.

Third, relevance heightens learning and application. Learning and teaching should not just be centered on learners’ needs and problems to boost motivation and effectiveness. Learning cannot be detached from its context.

Finally, nurturing cultures that support effective learning matters for performance and human achievement. Systems enabling peer reward and accountability build resilience.

Protect, invest, together in a learning workforce

Health policymakers are manifesting intent to act on the health workforce crisis.

Alongside urgent investments, applying systemic perspectives from learning innovations like those The Geneva Learning Foundation has pioneered presents a path to growing motivated, capable workforces ready for the challenges ahead.

Rethinking assumptions opens eyes – when we commit to support health workers holistically, the rewards radiate across health ecosystems.

Reference: Agyeman-Manu et al. Prioritising the health and care workforce shortage: protect, invest, together. The Lancet Global Health (2023). https://doi.org/10.1016/S2214-109X(23)00224-3

The imperative for climate action to protect health and the role of education

The imperative for climate action to protect health and the role of education

Reda SadkiGlobal health

“The Imperative for Climate Action to Protect Health” is an article that examines the current and projected health impacts of climate change, as well as the potential health benefits of actions to reduce greenhouse gas emissions. The authors state that “climate change is causing injuries, illnesses, and deaths, with the risks projected to increase substantially with additional climate change.” 

Specifically, the article notes that approximately “250,000 deaths annually between 2030 and 2050 could be due to climate change–related increases in heat exposure in elderly people, as well as increases in diarrheal disease, malaria, dengue, coastal flooding, and childhood stunting.” The impacts will fall disproportionately on vulnerable populations, and climate change “could force more than 100 million people into extreme poverty by 2030.”

The article discusses major exposure pathways that link climate hazards to health outcomes like “heat-related illness and death, illnesses caused by poor air quality, undernutrition from reduced food quality and security, and selected vectorborne diseases.” It also notes that “the effects of climate change on mental health are increasingly recognized.”

Importantly, the authors argue that “opportunities exist to capitalize on environmental data to develop early warning and response systems” to help adaptation efforts. Furthermore, “investments in and policies to promote proactive and effective adaptation and reductions in greenhouse-gas emissions (mitigation) would decrease the magnitude and pattern of health risks.”

The article highlights that “transitions in land, energy, industry, buildings, transportation, and cities” aimed at “limiting global warming to 1.5°C” would bring substantial public health benefits. For example, “strong climate policies consistent with the 2°C Paris Agreement target could prevent approximately 175,000 premature deaths” in the US by 2030. More broadly, the authors state that “policies to reduce greenhouse-gas emissions in the energy sector, housing, transportation; and agriculture and food systems can result in near-term ancillary benefits to human health.”

The review thus underscores that “protecting [public] health demands decisive actions from health professionals and governments” in tackling climate change through adaptation and ambitious mitigation policies that yield health “co-benefits.”

What is the role of education?

The review article presents clear evidence that climate change is already severely harming public health, with escalating threats projected, particularly for vulnerable communities. It rightly argues that responding effectively requires urgent adaptation and emissions reductions prioritizing those most impacted.

However, conventional top-down approaches to climate and health in global health are unlikely to achieve the rapid, scalable results needed. Such traditional modalities tend to be ponderously slow, generate knowledge not readily actionable, and fail to reach those on the frontlines in marginalized locales.

Building a new scientific field around climate and health may take years using conventional approaches.

What we would wish for instead is a decentralized, grassroots peer learning system that can directly empower and assist under-resourced local health workers confronting growing climate-health crises.

Specifically, a digital network interconnecting one million such frontline personnel to share granular insights on how climate change is damaging community health in their areas.

This system would facilitate collaborative design of hyperlocal adaptation initiatives tailored to each locale’s distinct climate-health challenges.

It would channel localized knowledge to shape responsive national policies rooted in lived realities on the ground.

Digital tools would amplify voices of those observing firsthand impacts too often excluded.

And participatory methods would synthesize nuanced community observations lacking in conventional statistics.

This locally-attuned, equity-oriented learning infrastructure could unlock community leadership to catalyze climate-health solutions where needs are greatest. 

It represents the kind of decentralized, rapidly scalable approach essential to address the review’s calls for urgent action assisting vulnerable groups most harmed by climate change.

Reference: Haines, A., Ebi, K., 2019. The Imperative for Climate Action to Protect Health. N Engl J Med 380, 263–273. https://doi.org/10.1056/NEJMra1807873

Illustration: The Geneva Learning Foundation Collection © 2024

Prioritizing the health and care workforce shortage

Prioritizing the health and care workforce shortage: protect, invest, together

Reda SadkiGlobal health

The severe global shortage of health and care workers poses a dangerous threat to health systems, especially in low- and middle-income countries (LMICs). The authors of the article “Prioritising the health and care workforce shortage: protect, invest, together”, including six health ministers and the WHO Director-General, assert that this workforce crisis requires urgent action and propose “protect, invest, together” to tackle it.

Deep protection of the existing workforce, they assert, is needed through improved working conditions, fair compensation, upholding rights, addressing discrimination and violence, closing gender inequities, and implementing the WHO Global Health and Care Worker Compact to ensure dignified working environments. All countries must prioritize retaining workers to build resilient health systems.

Significantly increased and strategic long-term investments are imperative in both training new health workers through educational channels and sustaining their employment. Countries should designate workforce development, especially at the primary care level, as crucial human capital investments impacting population health outcomes. Intersectoral financing is key, bringing together domestic funds, grants, concessional sources, and private sector partners into coordinated national plans. Global solidarity is required to resource-constrained LMIC health workforces.

Intersectoral collaboration between ministries of health, finance, economic development, education and employment can develop integrated health workforce strategies. South-South partnerships offer pathways for health worker training and mobility to address regional shortages. Small island nations confront severe but overlooked workforce obstacles requiring specially tailored policy approaches.

The severe projected health workforce shortfall urgently necessitates that actors globally protect existing health workers, strategically invest in growing national workforces, and unite intersectorally behind robust health employment systems, especially in lower resourced contexts. As the authors emphasize, “there can be no health, health systems, or emergency response without the health and care workforce.”

What about the role of education?

This article does not provide much direct discussion of health education systems related to the global health workforce shortage. However, it makes the following relevant points:

  1. Chronic underinvestment in the health and care workforce, including in education and training, has contributed to long-standing shortages.
  2. There is a need for strategic investments in health and care worker education and lifelong learning, with a focus on primary health care, to help address shortages.
  3. Investments in standalone health infrastructure will have little effect unless matched by investments in developing the health workforce through education and training.
  4. Increasing, smarter and sustained long-term financing is crucial for health and care worker education and employment.
  5. Regional and subregional collaboration should be explored to bring together resources and capacities for health workforce education and training.
  6. Intersectoral collaboration between health, education, finance and other sectors is important for developing policies and making investments in health workforce education.

Read more to understand what this means for health education: Protect, invest, together: strengthening health workforce through new learning models

Reference: Agyeman-Manu et al. Prioritising the health and care workforce shortage: protect, invest, together. The Lancet Global Health (2023). https://doi.org/10.1016/S2214-109X(23)00224-3

Illustration: The Geneva Learning Foundation Collection © 2024

Movement for Immunization Agenda IA2030

Movement for Immunization Agenda 2030 (IA2030): grounding action in local realities to reach the unreached

Reda SadkiGlobal health

Three years after the launch of Immunization Agenda 2030 (IA2030), WHO’s 154th Executive Board meeting provided a sobering picture of how the COVID-19 pandemic reversed decades of progress in expanding global immunization coverage and controlling vaccine-preventable diseases.

  1. Over 3 million more zero-dose children in 2022 compared to 2019 and widening inequities between and within countries.
  2. Africa in particular suffered a 25% increase in children missing out on basic vaccines.
  3. Coverage disparities grew between the best- and worst-performing districts in the same countries that previously made gains.

In response, the World Health Organization is calling for action “grounded in local realities”.

Growing evidence supports fresh approaches that do exactly that.

Tom Newton-Lewis is part of the community of researchers and practitioners who have observed that “health systems are complex and adaptive” and, they say, that explains why top-down control rarely succeeds.

  • The claim is that directive performance management—relying on targets, monitoring, incentives and hierarchical control—is largely ineffective at driving outcomes in low- and middle-income country health systems.
  • By contrast, enabling approaches aim to leverage intrinsic motivation, foster collective responsibility, and empower teams for improvement.

However, top-down control and directive management appear to have been key to how immunization programmes achieved impressive results in previous decades.

Hence, it may be challenging for the current generation of global immunization leaders to consider that enabling approaches that leverage intrinsic motivation, foster collective responsibility, and empower teams – especially for local staff – are the ones needed now.

One example of an enabling approach is the Movement for Immunization Agenda 2030 (IA2030).

What is the Movement for Immunization Agenda 2030 (IA2030)?

This is a locally-led network, platform, and community of action that emerged in March 2022 in response to the Director-General’s call for a “groundswell of support” for immunization.

In Year 1 (report), this Movement demonstrated the feasibility of establishing a large-scale peer learning platform for immunization professionals, aligned with global IA2030 goals. Specifically:

  • Over 6,000 practitioners from 99 countries joined initial activities, with 1,021 implementing peer-reviewed local action plans by June 2022.
  • These participants generated over half a million quantitative and qualitative data points shedding light on local realities.
  • Regular peer learning events known as Teach to Reach rallied tens of thousands of national and sub-national immunization staff, defying boundaries of geography, hierarchy, gender, and job roles in collaborative sessions with each other, but also with IA2030 Working Groups.

By September 2022, over 10,000 professionals had joined the Movement, turning their commitment to achieving IA2030 into context-specific actions, sharing progress and results to encourage and support each other.

In Year 2, further evidence emerged on participant demand and public health impacts:

  • By June 2023, the network expanded to 16,835 members across over 100 countries.
  • Some participants directly attributed coverage increases to the Movement (see Wasnam Faye’s story and other examples), with many sharing a strong sense of IA2030 ownership.

Overall, the Movement has already demonstrated a scalable model facilitating peer exchange between thousands of motivated immunization professionals during its first two years.

  • Locally-developed solutions are proving indispensable to practitioners, to make sense of generalized guidance from the global level.
  • Movement research confirmed that “progress more likely comes from the systematic application and adaptation of existing good practice, tailored to local contexts and communities.”
  • Connecting local innovation to global knowledge could be “instrumental for resuscitating progress” towards more equitable immunization, especially when integrated into coordinated action across health system levels.
  • It could be part of a teachable moment in which global partners learn from local action, rather than prescribe it.

The Movement has already been making sparks. It will take the fuel of global partners to propel it to accelerate progress in new ways that could meet or exceed IA2030 goals.

WHO Director-General says Immunization Agenda 2030 off-track

Widening inequities: Immunization Agenda 2030 remains “off-track”

Reda SadkiGlobal health

The WHO Director General’s report to the 154th session of the Executive Board on progress towards the Immunization Agenda 2030 (IA2030) goals paints a “sobering picture” of uneven global recovery since COVID-19.

As of 2022, 3 out of 7 main impact indicators remain “off-track”, including numbers of zero-dose children, future deaths averted through vaccination, and outbreak control targets.

Current evidence indicates substantial acceleration is essential in order to shift indicators out of the “off-track” categories over the next 7 years.

While some indicators showed recovery from pandemic backsliding, the report makes clear these improvements are generally insufficient to achieve targets set for 2030.

While some indicators have improved from 2021, overall performance still “lags 2019 levels” (para 5).

Specifically, global coverage of three childhood DTP vaccine doses rose from 81% in 2021 to 84% in 2022, but remains below the 86% rate achieved in 2019 before the pandemic (para 5).

The number of zero-dose children fell from 18.1 million in 2021 to 14.3 million in 2022. However, this number is still 11% higher compared to baseline year 2019, when there were 12.9 million zero-dose children (para 10).

Furthermore, the report stresses that recovery has been “very uneven” (para 6), with minimal gains observed in low-income countries:

“As a group, there was no increase in DTP3 coverage across 26 low-income countries between 2021 and 2022.” (para 6)

Regions are also recovering unevenly, especially Africa.

“In the African Region, the number of zero-dose children increased from 7.64 million in 2021 to 7.78 million in 2022 − a 25% increase since baseline year 2019.” (para 6)

Inequities within countries also continue expanding, with gaps widening “between the best-performing and worst-performing districts” since 2019 (para 6).

The top priorities (para 34) include:

1) “Catch-up and strengthening” immunization activities
2) “Promoting equity” to reach underserved communities
3) “Regaining control of measles” with intensified responses
4) Advocacy for “increased investment in immunization, integrated into primary health care”
5) “Accelerating new vaccine introduction” in alignment with WHO recommendations
6) “Advancing vaccination in adolescence” such as HPV vaccine introduction

The report stresses that “coordinated action” on these priorities can get countries back on track towards IA2030 targets in the wake of COVID-19 disruptions (para 27).

What is needed, says WHO, is “grounding action in local realities” (para 32) to reach underserved areas thus far left behind.

Given this context, this document asks: “What actions can global partners take to support countries to accelerate progress in the six priority areas highlighted?” (para 37).

In response, WHO contends that “the operational model under IA2030 must continue shifting focus to the regional level, to facilitate coordinated and tailored support to countries.”

It is unclear how devolution to the regional level could truly respond to highly localized barriers and enablers.

Such a claim may best be understood with respect to the internal equilibrium between WHO’s Headquarters (HQ) and the Regional Offices, with IA2030 being initially driven by HQ.

What other changes might be needed? And what are the barriers that might hinder global immunization partners from recognizing and supporting such changes?

Reference: Tedros Adhanom Ghebreyesus, 2023. Progress towards global immunization goals and implementation of the Immunization Agenda 2030. Report by the Director-General, Executive Board 154th session Provisional agenda item 9. World Health Organization, Geneva, Switzerland.

Illustration: The Geneva Learning Foundation Collection © 2024