The Communication Gap is a Critical Barrier to Closing the Implementation Gap
During the last quarter of 2011 one of the most striking and saddening experiences for me was to witness at first hand how key information appeared not to be in the possession of policy makers and techno-professionals for whom this information is targeted in the first place. How can we expect action to be taken if the key actors do not know or appear not to be aware of what they are expected to do? We have discussed the “Implementation Gap”, the “know - do - gap” the so called “low hanging fruits”. How can the low hanging fruits be picked if we do not know what these fruits look like and where they can be found? How can we expect global, regional and national resolutions, policies and technical frameworks to be acted upon if they do not reach the implementers?
Here is an example. The WHO Regional Office for Africa convened a very well attended meeting in Pretoria in October 2011 on the important subject of Human Resources for Health. My presentation was on “New Directions in Health Professionals Education and Training”. I asked the audience how many of them were aware of the frame work developed by the Global Health Workforce Alliance (GHWA) known as Country Coordination and Facilitation (CCF). Very few hands went up. At another forum, not to be disclosed, I discovered that most Health Ministers interviewed were not aware of the CCF. At a workshop in another country, the most senior technical head of the Ministry was not aware of the CCF. Here is the problem.
In 2009, GHWA conducted dissemination workshops for this CCF in Accra and Ouagadougou for English and French speaking countries respectively. There were participants from multiple sectors including health, education, finance, and public service and civil society from all the African countries. I was at the Accra dissemination meeting. Similar workshops were conducted in Asia and South America. Further, during the 2nd Global Forum on Human Resources for Health in Bangkok in January 2011 there was another workshop on the CCF organized by GHWA. The CCF can also be found on the GHWA website and is being implemented in some countries. How come that the existence of this framework which holds potential for transforming health workforce development in countries has not caught fire and spread?
Certainly we cannot blame GHWA and WHO. I believe they have done their part at high cost too although I am going to ask them to do more. It is the communication and management practices inside health ministries in the countries that appear to be the root cause of this deadly know– do-gap. What happened after the dissemination workshops in Accra, Ouagadougou and Bangkok? Did those delegates who participated write debriefing reports to their leaders make presentations to them and follow them up? Were there any efforts to hold national dissemination workshops as was advised? Did the participants go back home to business as usual? This is just one example. There are so many global, regional and national resolutions, policies and frameworks that are not being implemented to scale just because of similar communication gaps. I am informed that if we asked our leaders both political and technocratic to list just three of the nine MDGs, we would be amazed by the results.
There is a saying that “nothing really important ever happens until the climate of opinion is right”. Creating that right climate of opinion inside complex institutions such as ministries, governments and society remains a continuing challenge. I would like to hear from you all how we can improve on this. Many of you must have useful experience and suggestions to share.
Comments (16)
Josephine Kibaru-Mbae
Ministries of Health is a big challenge. It is in very few instances when the senior policy makers are on top of all that is happening, many are the times when the line Manager of the issue at hand, is the only one aware of global developments. Some Ministries have senior management forums where some matters are supposed to be discussed, but in most instances global issues get overrun by national issues, which always appear urgent and with immediate repercussions. It is only when Ministries receive reminders from
Global institutions such as WHO etc, when they rush around getting feedback from the technical persons responsible.
I would suggest that ministries strengthen their International Relations offices, which would act as the coordinating unit, keeping everybody on their toes on the global issues through structured meetings. Maybe then some of these issues, may be heard and internalized by all who need to be in the know.
Dela Dovlo
Happy New Year greetings!
Excellent topic to start the year with.
My sense of this issue is that, part of the problem arises because as technical experts and professionals, after spending months and years of discussion and research developing these tools, we expect countries to accept them, gain consensus with their internal stakeholders, and then implement these after a 2 day "dissemination" by the experts.
I think we generally under estimate what it takes to shift an existing process and experience to a new approach, and it is often unclear to me, what the support, motivators and incentives are to take these interventions forward for those we disseminate to. This is particularly so when the next week or year, another group of experts from elsewhere (sometimes including the same persons as before) introduce something similar, or even completely different.
I believe that each global framework, tool or policy advice, requires a country/implementation process almost similar to the development process itself and should include allowing the tool to be tailored to local needs.
Thus I think this goes beyond communication and dissemination and often funds are not available for the in-country processes.
Having said all that, I believe it also boils down to....., if countries have a felt need and health leadership that truly is aimed at producing results for their citizens........., a previous topic.
Thank you
Dela Dovlo
Gerald Gwinji
On my desk every week I do receive an average of three 'policy/strategy' change advice documents, usually quite detailed and voluminous, most without executive summaries and on which 'consultants will have worked on meticulously for months and only on that too! We have strategic plans that span 3 to 5 years and I would be like chameleon to roll over every few weeks some new idea or innovation is re-invented. I am expected to read and comment feedback and even 'move with speed to implement'? This does not work in a government setting in which: my ministry and indeed myself are a small part of one big integrated machinery. Remember what happens in one area of government has ripple effects on others. You cannot take policy/strategy decisions without due consultation. Such consultation is via several fora including parliaments and cabinet- just try to hurry these and see how successful u are. Also remember those as the 'top" are both techno- and political appointments whose tenors of office vary from a few months hopefully to a few years! Get into office today and every corner of experts and advisors expect you to know all matters on the table, including some declaration made by 5 delegates in a small meeting decade ago? All converges on one office so make your approach with that in mind! A few of us are lucky to have very supportive technical colleagues in our flanks!
That's where the strengths lie!
YOSWA DAMBISYA
A happy new year to you all!
The issue raised is quite pertinent, and I am happy that we are beginning to receive responses from different perspectives. Evidently, it is a complex problem, especially in view of the PS's submission below regarding the volume of technical documents high level policy makers are flooded with.
What I find puzzling, however, is the fact that it is often the very top policy makers (heads of state, ministers, PSs...) who meet and take decisions upon which some of those voluminous documents are developed. Then when the product (which presumably responds to identified need) is produced it is literally left to gather dust. The message for me is that perhaps we assign the wrong prescription to the identified gaps. But then what does one make of the lack of *dissemination* of international policy decisions - task shifting and the Global Code come to mind - which are adopted at high level but with lots of technical input?
I note the ECSA DG's suggestion to strength information departments at country level. I would add that that should be coupled with strategies to improve demand for such information as well; otherwise, the most well-packed information will remain under-utilized.
Participatory approaches to generation of information/research are often promoted to ensure ownership of the final product. The question, of course, remains at what level can the MoH be involved? It is unlikely that the minister, PS or Directors will have the time to get actually involved in the research itself, the best one can hope for is their endorsement of the idea and participation in a feedback session or two. Lower level technocrats will be involved, but in the end, the findings and recommendations will be new to those whose action will be required to give effect to the voluminous reports.
The dynamics of strategy/policy change at country level is well put by the
PS, equally hard to manipulate may be work plans. Which leaves one wondering how to ensure uptake of any information generated between those strategies/policies/work plans. At another level, I see this as the same problem experienced at operational level where health practitioners do not change their practice to reflect evidence, even of high impact interventions (the know-do gap alluded to by Prof Omaswa).
May I suggest that those of you that convene high level forums devote a session or two to the alarm sounded by Prof Omaswa.
Best regards,
Yoswa
John Donnelly
These responses to Francis' questions and points have been really interesting -- and all valid.
But how about a more basic response: Couldn't we communicate better?
If those responsible for pushing through policy recommendations on an international level took more responsibility to communicate those recommendations, there would be a much better chance for them to catch on.
Often communications is the orphan of the policy process and more attention to it would increase odds of success in implementation.
Some ideas:
* Organize South-South meetings (a big hit with MLI (Ministerial Leadership
Initiative) and others) that feature early implementers and give candid assessments that highlight the good and the bad.
* Write. Create some buzz around the policy recommendation by putting out blog posts (not as difficult a barrier to climb as you would think for those who don't yet), posting to Facebook, writing a perspectives piece for the Lancet, or an op-ed for the Guardian's semi-new web site on global development.
* Champion your racehorses, or early implementers, and get them to write about the experience, as well as host panels at conferences on the issue.
The idea is to beat the drum. Take advantage of the opportunities to communicate in the great world of social media. Crow early and often.
Cheers,
John Donnelly
OKELLO, Dr. David - ng
Agreed.
Francis Omaswa
Greetings.
This is very excellent and full of insight. Can we share it with the whole group?
Cheers
Francis.
Dr David Okello
I agree with you that communication gap lead to implementation gap; and indeed we should do more to disseminate critical information to policy-decision makers. But implementation gap is not just due to knowledge gap. The debate on implementation gap must examine other factors contributing to it. I will elaborate just a few. Too rapid changes in personnel at policy-decision making level is a major problem. Each time I visit countries I work with (usually on annual basis) over 50% of senior teams at the health headquarters are completely new people. The lifespan of a ministerial posting is just about one year on the average. Permanent Secretaries are not permanent anymore. These changes have negative impact on implementation. Institutional memories get lost with too many changes. Other factors include time and costs involved in implementation, resistance to change in the work setting, facilities are inadequate for implementation; and implementation of research findings in particular is difficult because they are not always packaged in ways that are user-friendly to policy-decision makers. Moreover, sometimes the political environment is not right for implementation. For example, it may not be politically popular to charge user fees. However, economic realities may necessitate the introduction of user charges in order to sustain and maintain quality services.
Thank you.
Dr David Okello
WR/Nigeria
omaswa Francis
Greetings.
This is very excellent and full of insight. Can we share it with the whole group?
Cheers
Francis.
Kayode Odusote
Dela Dovlo
Happy New Year greetings!
Excellent topic to start the year with.
My sense of this issue is that, part of the problem arises because as technical experts and professionals, after spending months and years of discussion and research developing these tools, we expect countries to accept them, gain consensus with their internal stakeholders, and then implement these after a 2 day "dissemination" by the experts.?
I think we generally under estimate what it takes to shift an existing process and experience to a new approach, and it is often unclear to me, what the support, motivators and incentives are to take these interventions forward for those we disseminate to. This is particularly so when the next week or year, another group of experts from elsewhere (sometimes including the same persons as before) introduce something similar, or even completely different.
I believe that each global framework, tool or policy advice, requires a country/implementation process almost similar to the development process itself and should include allowing the tool to be tailored to local needs.
Thus I think this goes beyond communication and dissemination and often funds are not available for the in-country processes.
Having said all that, I believe it also boils down to....., if countries have a felt need and health leadership that truly is aimed at producing results for their citizens........., a previous topic.
Thank you
Dela Dovlo
solomon worku
Hope this e-mail finds you well. I am really happy for the identified information gap. much have been said and I do totally agree with the compliments.
Regards
Solomon
Hon Dr Sam Agatre Okuonz
Happy New Year greetings to you and all the colleagues! This is a fascinating discussion. But it is an old discussion by students of health policy. It is really about policy implementation, in which communication makes a critical but grossly inadequate contribution to policy implementation. I have not yet come across a comprehensive solution to implementation. Different approaches provide different levels of dividends in implementation. The closest to what appears to be a perfect framework for implementation is embodied in the 10-point principles in Policy for the real world by Hogg wood and Gunn, 1984. See pasted below. In addition, I did study, some years back, many initiatives, policies and programs in MoH in Uganda as part of my PhD to find why these were not implemented and in summary I found that the problems and solutions were defined ( typically by researchers, donors etc) without the involvement of local people, including policy makers, implementers and beneficiaries. The conclusion is that implementation potential increases with 1) an agreed definition and assessment of a problem, 2) people's views about the identified problem,solutions and potential benefits; 3) economic benefit analysis, including assessment of resource availability and adequacy ; 4) administrative and political feasibility, and 5) continous feedback into implementation through M&E. I find that most of our research generated policies or donor initiated programs are narrow, inadequate and generally lacking in the dimensions above and below.
The ten point principles of perfect implementation are below:
1. There should be no crippling external factors.
2. Time and resources should be adequate for the expected results.
3. The required combination of resources should be available.
4. The cause-effect theory in the policy / program design should be valid.
5. The cause-effect relationship should be direct.
6. Dependency on external factors or actors should be minimal.
7. There should be perfect understanding and agreement on the objectives.
8. Activity tasks should be in the correct sequence.
9. There should be perfect communication and coordination.
10. There should be perfect compliance to management and policy guidelines
by implementers.
I will appreciate your comments. Very best, Sam
Hon Dr Sam Agatre Okuonzi, MP
MD (Mak), MSc (Lond), PhD (Berg)
Innovision Health & Social Policy Consult
P.O. Box 72995, Kampala, Uganda
Tel: +256(0)711504846, +256(0)772504846
Christopher Samkange
Dovlo and Gerald Gwinji because these two very correctly, in my view,
presented the other side of the process. As that is the final common
pathway, we cannot ignore the pertinent issues they raised.
Sheilla Matinhure
I have been following the discussion on the subject of this E-mail and would also wish to add my voice from the perspective of translating evidence into policy. I believe there is more to it than just communication. It is a known fact that credible knowledge, even from Randomized Controlled Trials (RCTs) continue to gather dust in many shelves without adding value to policy change or influencing practice.
In a study that we conducted sometime in 2007, in relation to policy formulation we found several factors that influence up-take of evidence into policy. These included:
1 Local involvement in evidence production- where local researchers were involved in international multi-centre studies, the findings were seen as having greater credibility & applicability given the country context.
2. Interactions between research and experiential knowledge, prior practices and beliefs
3. Evidence from RCT being congruent with existing practice made uptake of evidence into policy was easier
4. The need and existence of champions to push the policy agenda
5. Involvement of researchers in policy making as opposed to evidence being perceived as coming from elsewhere and being imposed on policy makers
6. The role of stakeholders that expressed varied and contested interests, most often differing in their use and interpretation of evidence, and promoting different policies (depending on their agenda)
7. Political agenda and country priorities. If the country has other pressing priorities, seemingly best practices may not be given preference.
8. The overall political and economic context in which knowledge translation is expected to take place is also an important factor.
Some of the lessons Learnt were:
There is openness among policy makers to consider research evidence and new initiatives
Local researchers were more open to the findings of research in which they had been involved
Local champions are important and are a potential route for facilitating knowledge transfer
National, regional and international networks appear to be very important in both shaping ideas about what constitutes evidence and in acting as a conduit for transfer of research findings
Context is an important filter for the translation of knowledge at local levels, i.e. with reference to issues of local applicability of evidence
Strong international evidence may not always be locally accepted.
I note that some of the points above have also been observed and mentioned by Dr Gwinji, Dolvo and Okuonzi.
Sheillah Matinhure
Manager for Human Resources for Health and Capacity Building
The East, Central and Southern African Health Community
Plot 157, Oloirien, Njiro Road
P.O.Box 1009,
Arusha, Tanzania
Tel: 255-27-254 9362, 254 9365/6
Fax: 255-27-254 9392
Mobile: +255 75304 8970.
George Melville
some of my thoughts
The communication gap and implementation is a serious challenge not only in the health sector but also affects other sectors and may be one of the factors responsible for the lag in development of our countries.
Let me make the following contributions
1. Too little time to communicate for engendering implementation
Too often the same technocrats attend the same workshops/meetings gather relevant information return home and wait for the next meeting. In this regard there is little time to provide feedback for implementation. Even at the country level we are all familiar with the workshop syndrome where health workers spend over 50% of working time attending workshops with little time to implement what has been learnt
2 Responsibility and accountability
Technocrats and policy makers must be held accountable for the communication of outcomes of meetings, new policies and ensuring their implementation
? I do know of a particular country in the continent, where at cabinet level, Ministers are required to report on all meetings attended by officers, the outcomes and what actions to be taken to implement the outcomes.
? We may also want to recollect some of the health reforms in some countries in West Africa that brought into action Top Management Teams that meet weekly to discuss in advance weekly activities, reports of meetings and implementation plans.
3. GHWA, WHO and ACHEST
I do agree with Francis that the CCF has the potential to make lasting changes in the workforce situation in our countries. We need to do more GHWA and WHO. There have been earlier discussions that a crop of elder African health professionals as change agents can make a difference by fostering transformational/attitudinal change in African countries by targeting top health and government policy makers with the challenges regarding the translation of policies to action in HRH and health in general. HRH (CCF in particular) as a health systems issue can be an entry point. ACHEST can dialogue with GHWA and WHO as to what role and leadership it can play in this direction.