Introduction

This edition addresses a recurring challenge within many health systems, the ‘know-do gap’, or the difficulty of translating knowledge into practice. This challenge has been a recurring theme across multiple editions of the South African Health Review (SAHR) and is linked to the difficulty of translating policy into action, the uneven spread of successful innovations, and the challenge of sustaining learning over time. In other words, although the South African health system generates enormous amounts of data, experience and (often unseen) innovation, it has been recognised that these are not clearly translated into service or system-wide performance improvements.

The idea of a learning health system initially came into global health system discussions via the quality improvement world, following a 2007 workshop organised by the then US Institute of Medicine.1 The workshop considered what needed to be done to strengthen the way evidence was generated and used to improve health and health care. More recently, the Alliance for Health Policy and Systems Research (AHPSR) of the World Health Organization has argued that, across low- and middle-income countries, developing learning health systems is a strategic, but largely ignored, investment to improve all dimensions of health system performance, including fostering increased adaptivity and innovation.2

Although the importance of learning in quality improvement is recognised in South Africa, for example, through widely-used tools such as the ‘plan-do-study-act’ (PDSA) cycle, the broader idea of a learning health system is less familiar. It has, however, been applied in understanding experiences of continuous quality improvement and collaborative learning for primary health care in KwaZulu-Natal,3,4 and has also been identified as part of strengthening the District Health System.5 This edition of the South African Health Review adds to this emerging body of knowledge by presenting a wider range of relevant experiences, and illustrates the considerable range of learning approaches, collaborations, and challenges of turning knowledge into practice within the country.

Overview of the edition

This volume of papers is structured around five sections.

Learning in context

Addressing why learning matters in the South African health system, the first section presents this editorial and the overall outline of current health and related indicators. Ndlovu and colleagues demonstrate the wealth of data generated by the South African health system, highlighting both the improvements and challenges in critical indicators and the data governance, integration and accountability weaknesses that constrain the system’s ability to translate indicators into timely action. The paper sets the scene for the rest of the volume by establishing the need to consider how information can become actionable knowledge that improves health system performance.

Learning from information

The second section examines how the health system converts data, information and experience into actionable knowledge. Together, the papers show that generating information presents opportunities to learn, but also that learning depends on the availability of the organisational and human capabilities needed to interpret and use it.

Drawing on experience from four metropolitan and rural sub-districts in the Western Cape, Collyer et al. examine how data can inform decision-making and support improved health outcomes. The paper argues that learning emerges from the interaction of data systems, an adequately skilled and motivated workforce, and enabling organisational processes and culture.

Focusing on ward-based primary health care outreach teams in Ekurhuleni District, Ndombi, et al. explore the implementation of a mobile health application used by community health workers. This experience provides insights into the opportunities and challenges of using digital technologies to strengthen information flows, continuity of care and frontline decision-making. It demonstrates the need to tackle key organisational barriers in pursuing digital health integration within the health system.

Also based in Ekurhuleni District, S Pillay and colleagues evaluate the introduction of integrated chronic disease clinical stationery in primary health care facilities. This paper shows how improved clinical information systems can support disease management and continuity of care, as well as how standardised documentation practices are important for future data use. However, it also demonstrates the practical realities and challenges to implementation in busy service settings.

Finally, taking a national perspective, Mthethwa, et al. describe the development of the Health Systems Trust’s Good Practices Repository that documents and disseminates implementation knowledge from across South Africa. The paper not only demonstrates the range of local innovations being developed, but is also a first step to support broader health system learning, illustrating how experiential knowledge can be captured and shared.

Learning together

The third section explores learning as a social process shaped by participation, dialogue, collaboration and collective reflection. Together, the papers in this section show that learning is strengthened when knowledge is generated and interpreted collectively by groups of people.

Drawing on experience with community health workers in Mpumalanga Province, D’Ambruoso, et al. examine how a participatory learning intervention strengthened community health workers’ community-level mobilisation and collective problem-solving. The paper highlights the role of communities and frontline primary health care workers as active contributors to health system learning.

Working in three Western Cape sub-districts and drawing from the Healthy Futures South Africa initiative that supports community-oriented primary care, Reid, et al. describe the creation of learning circles and forums that bring together communities, health service staff, researchers and civil society organisations. The paper illustrates how deliberate structures for dialogue can foster learning across organisational boundaries.

Focusing on the Cape Winelands District, Sekhesa and Olivier investigate if and how learning occurs within health systems through responsiveness mechanisms such as patient complaint systems, health system and social reporting processes, and community, health system and wider political governance structures. The paper demonstrates both the learning potential of these feedback mechanisms, and the barriers to learning, created for sub-district teams by organisational hierarchies, power dynamics, and resource constraints.

Drawing on six health and nursing research collaborations from across South Africa, Boersema and Van Rensburg explore how trust, shared purpose, leadership, and role clarity shape successful research partnerships in nursing and health care. The paper offers lessons for strengthening collaboration to support learning for continuous healthcare improvement.

Finally, Suleman, et al. examine a community of practice, the Africa Health Professions Education Extension for Community Healthcare Outcomes (Africa HPE ECHO) network. Their paper demonstrates how peer engagement, reflective dialogue and shared learning can support health educator development and educational change.

Learning through practice

The fourth section focuses on the learning that emerges through implementation, experimentation and improvement. The papers show how practical experience becomes a source of adaptation and innovation.

Examining the Sishen Iron Ore Company Community Development Trust’s Health and Wellness portfolio in mining-affected communities in the Northern Cape and Limpopo, Renkin and Hugo apply community-oriented primary care and complexity theory to understand fragmented health initiatives. Highlighting implementation experiences that reveal fragmentation in health programmes, the paper also presents lessons for more integrated service delivery as well as challenges in implementing these lessons.

Working across four districts in three provinces through the Mphatlalatsane maternal and neonatal health programme, Odendaal, et al. examine how quality improvement teams learnt and adapted their own processes over the course of the COVID-19 experience. The paper highlights the importance of the interactions among advisors, leaders, members, and facility context in sustaining quality improvement.

Focusing on the Siyakubona ultrasound training programme, Seopela, et al. evaluate a mentorship model supporting midwives across six provinces. The paper demonstrates how virtual mentoring and peer support helped support post-training skill retention and remote ongoing clinical learning in primary health care.

Pillay and Moodley explore simulation-based learning in audiology education and its relevance to South Africa’s district health system. Their paper argues that such experiential learning, supported by simulation designs that reflect real world contexts, can better align professional training with service needs and population health priorities.

Examining responses to the COVID-19 pandemic, Sibanda, et al. analyse how universities, researchers and policy actors adapted during a major crisis, highlighting innovation, resilience and persistent structural inequalities.

Learning for emerging priorities

The fifth and final section considers how health systems learn in response to emerging risks, changing priorities and previously neglected needs.

Stevens, et al. examine efforts to embed gender-affirming healthcare within the South African public health system, showing how learning can involve questioning assumptions and reframing service responses to promote inclusion and equity.

Drawing on the experience of the Aurum Institute following a ransomware attack, Paterson, et al. explore how organisations learn from crises. The paper demonstrates how preparedness, governance and recovery processes contribute to resilience in digital environments.

Working in the Cederberg subdistrict of the Western Cape, Mash, et al. present a participatory approach to assessing climate vulnerability and environmental sustainability in primary health care facilities. The paper shows how structured reflection can help health services incorporate learning on climate adaptation and mitigation into primary care systems; although long-term infrastructure changes will need substantial resources.

Taken together, the papers in this volume demonstrate that significant learning is being produced across diverse settings within the South African health system, but that this learning is often localised rather than widely shared and institutionalised. They also highlight eight critical challenges that limit or undermine health system learning, ranging from individual and organisational capability weaknesses, to the routine demands of service delivery, to focusing on localised learning and pilot innovations that are not owned or sustained more widely (Table 1).

Table 1.Challenges to learning and system adaptation revealed across papers
Challenge Experiences reported (with exemplar chapters) Core consequences for health system learning
Variable learning capabilities Gaps in, for example, quality data, data use, digital literacy, leadership (e.g., D’Ambruoso, et al.; Ndlovu, et al.) Limits learning at both individual and organisational level
Competing priorities and workloads Service pressures, time availability limits, crisis responses, administrative burdens (e.g., D’Ambruoso, et al.; Pillay, et al.) Limits reflection, experimentation and collective learning
Organisational fragmentation and silos Disconnected initiatives, fragmentation across programmes and organisations, weak coordination (e.g., Mthethwa; Renkin and Hugo; Reid, et al.; Sekhesa and Olivier; Suleman, et al.) Prevents collective knowledge generation and system-wide learning
Hierarchies and power imbalances Organisational, societal and knowledge hierarchies, unequal participation in learning processes, including limited community voices (e.g., Boersema and Van Rensburg; Collyer, et al.; Reid, et al.; Sekhesa and Olivier; Sibanda, et al., Stevens, et al.) Restricts inclusive dialogue, collective sense-making and systemic response
Resource constraints Staffing shortages, digital infrastructure limitations, funding pressures (e.g., Renkin and Hugo; Mash, et al.; Ndombi, et al.; Paterson, et al.; Pillay and Moodley; Renkin and Hugo; Seopela, et al.; Pillay, et al.) Limits protected time, capacity and opportunities for learning
Weak knowledge sharing mechanisms Poor documentation, limited dissemination (e.g., Mthethwa, et al.; Stevens, et al.) Valuable experience remains local and learning does not spread
Difficulty translating local learning into system change Learning and other innovations remain at local level, successful pilots do not spread or scale-up (e.g., Collyer, et al.; Mthetwa, et al.; Ndombi, et al.; Pillay, et al.) Learning remains isolated rather than transforming broader system performance
Sustainability challenges Dependence on projects to support learning and innovation, leads to funding uncertainty, weak institutional ownership (e.g., Collyer, et al.; Ndombi, et al.; Odendaal, et al.; Reid, et al.) Learning remains isolated rather than transforming broader system performance

Looking to the future: the benefits and pathways to strengthening learning in the South African health system

Despite the challenges revealed, the papers included in this volume clearly demonstrate the benefits of strengthening the South African health system as a learning system. Learning in and through the system supports:

Better use of knowledge for decision-making and improvement

Learning enables the health system to translate data, evidence and experience into better informed action. The papers by Collyer, et al., Mthethwa, et al., and Pillay, et al. illustrate how routine data, indicators, clinical information, and implementation knowledge can support decision-making, whilst those by Odendaal, et al. and Ndombi, et al. show how learning can drive ongoing service improvement and innovation.

Stronger people and professional capability

Learning develops the skills, confidence, and adaptive capability of health workers, managers, and educators. The papers consider community health workers’ community mobilisation competencies (D’Ambruoso, et al.), the retention of clinical skills among midwives (Seopela, et al.), and how simulation and communities of practice contribute to health professional development (Pillay and Moodley; Suleman, et al.).

Stronger relationships and collaboration

As learning is strengthened through dialogue and collective problem-solving, learning processes that connect communities, health staff, researchers and other health system agents offer the possibility of stronger relationships and collaboration, which in turn support responsiveness (Boersema and Van Rensburg, D’Ambruoso, et al., Mash, et al., Reid, et al., Sekhesa and Olivier).

Stronger organisational and health system functioning

Learning helps organisations capture, share and institutionalise knowledge. The papers by Collyer, et al., Mthethwa, et al., Paterson, et al., and Reid, et al. demonstrate mechanisms for generating and using lessons, while those by Odendaal, et al. and Pillay, et al. show how continuous improvement can become embedded within routine organisational practice.

Greater adaptation, equity and resilience

Learning enables health systems to respond both to uncertainty (such as adaptation during COVID-19: Sibanda, et al.), as well as to previously neglected needs (e.g., climate and cyber threats: Mash, et al. and Paterson, et al., respectively), and population groups (Stevens, et al.).

Consistently securing these five benefits will, however, require new ways of thinking and acting that address the existing challenges to learning (outlined in Table 1). The papers suggest four key starting points:

Recognising that learning involves more than information and data

The papers demonstrate that data and evidence do not by themselves influence decisions or change practice (e.g., Collyer, et al.), and that simply introducing digital systems does not automatically improve services (e.g., Ndombi, et al.). As Sheikh and Abimbola2 argue, learning only occurs when information is interpreted, discussed and acted on; in other words, learning depends on the interaction among information, deliberation, and action.

Understanding learning requires a process of collective, rather than individual, sensemaking

The papers in this volume offer particularly rich insights into the fundamentally social nature of learning. They show that learning occurs when people come together, for example through learning circles (Reid, et al.); communities of practice (Suleman, et al.); quality improvement teams (Odendaal, et al.); and participatory action research processes (D’Ambruoso, et al.), and work together to interpret information and develop shared responses to complex problems. Some papers also demonstrate how learning happens as a result of reflecting on experience, such as introducing new clinical information systems (Pillay, et al.); responding to a cyber-attack (Paterson, et al.); conducting collaborative research (Boersema and Van Rensburg); simulation-based learning (Pillay and Moodley), and assessing and responding to climate vulnerability and environmental sustainability risks (Mash, et al.). Learning-through-doing is important because team reflection is most powerful when grounded in real-world experience, and improvement usually emerges through repeated cycles of action and adjustment.

Many papers also specifically demonstrate the role of frontline health workers as key learning teams and show that critical learning occurs closest to service delivery (e.g., Collyer, et al.; D’Ambruoso, et al.). However, a broad range of other actors are also important, including communities and patients, managers, researchers and partner organisations. Engaging such diverse groups in learning processes helps surface multiple perspectives, identify overlooked challenges, and generate insights and action grounded in local realities (e.g., Reid, et al.; Renkin and Hugo; Sekhesa and Olivier).

Paying attention to the forms of learning

In strengthening the South African health system as a learning system, attention must be paid to the forms of learning, or learning loops, that are encouraged.2 Single-loop learning supports improvements in existing practices or routines (e.g., Renkin and Hugo; Ndombi, et al.; Seopela, et al.; Pillay, et al.), whereas double-loop learning supports system development by re-examining and challenging existing assumptions about how problems are defined and addressed (e.g., Boersema and Van Rensburg; Reid, et al.; Sekhesa and Olivier; Sibanda, et al.; Stevens, et al.), and triple-loop learning contributes to improvements in how the system learns (e.g., Collyer, et al.; D’Ambruoso, et al.). Although single-loop learning can be supported by more ‘technical’ interventions, such as quality improvement methods and digital innovations, double-loop learning requires social learning processes. The papers show that such learning is based on active participation by multiple learning partners; protected spaces for reflection and dialogue; the willingness to question existing assumptions and power relationships; and mechanisms for translating new understandings into action. In other words, for double-loop learning to occur, the health system must become capable of interrogating not only its performance, but also the beliefs, structures, and problem-framings that shape that performance.

Few papers in this volume, or that are already published, offer experiences of triple-loop learning, perhaps suggesting that there has been only limited effort to date to improve the South African health system’s overall learning capability. This suggests that a critical challenge for the future is connecting, sustaining and scaling existing learning processes so that they become a collective system capability rather than a series of isolated experiences.

Institutionalising learning processes and practices

Developing this systemic and collective learning capability requires institutionalising learning processes and practices. As Sheikh and Abimbola2 outline, attention must be paid to:

  • Embedding learning within existing structures and routines (such as regular monitoring and evaluation and patient feedback processes), rather than creating isolated learning projects.

  • Investing in and mandating human capacity for learning; for example, developing facilitation and mentoring skills to support sensemaking, as well as data literacy, establishing learning forums or communities of practice that allow collaborative learning, and authorising and incentivising learning through routine performance management processes.

  • Developing the enabling conditions that support learning; such as relevant leadership practices, institutional culture, system design and resourcing.

The papers in this volume also offer practical insights into what is entailed in this third point of establishing enabling conditions. They highlight the importance of:

  • Relevant leadership practices, such as: creating structures that enable dialogue across hierarchical levels (Reid, et al.; Sekhesa and Olivier); motivating and enabling others (D’Ambruoso, et al.; Odendaal et al.); connecting actors and facilitating collaboration (Boersema and Van Rensburg; Reid, et al.); treating crises as opportunities for organisational learning (Paterson, et al.); strengthening governance arrangements to support learning processes (Collyer, et al.); and adaptation and innovation (Renkin and Hugo; Mash, et al.).

  • Trusting relationships and inclusive spaces for social learning that are supported by: creating safe spaces for reflection and dialogue (Collyer, et al.; Reid, et al.; Suleman, et al.); valuing experiential and community knowledge alongside formal evidence (D’Ambruoso, et al.; Mash, et al.); developing mechanisms and processes for collective sensemaking around data and experience (Collyer, et al.; Sekhesa and Olivier); and supporting collaboration between diverse actors including researchers, managers, practitioners, and communities (Boersema and Van Rensburg; Reid et al.).

  • The purposeful investments that establish learning as a core element of health system functioning, rather than just a luxury: protecting time for learning (D’Ambruoso, et al.; Pillay and Moodley; Seopela, et al.; Suleman, et al.); strengthening data-use and interpretation capabilities alongside information systems and relevant infrastructure (Collyer, et al.; Paterson, et al.); sustained support for learning and improvement initiatives (Odendaal, et al.; Seopela et al.); and resourcing mechanisms that routinely document and share experience (Mthethwa, et al.).

Ultimately, this edition of the SAHR suggests that becoming a learning health system is an essential priority in the continuing work of strengthening the South African health system. The benefits of systemic learning are too valuable to ignore: better use of knowledge for decision-making and improvement, stronger people and professional capability, stronger relationships and collaboration, stronger organisational and health system functioning, and greater adaptation, equity and resilience. Achieving these benefits will require social and political action to address the inevitable challenges and resistance, and to drive new engagements and processes. Investment in people rather than only technology is important, alongside the deliberate development of learning spaces and structures as well as purposeful efforts to value participation, trust, and reflection. Organisational and social environments must be created within the health system in which people, including communities and frontline health workers, are able, supported, and encouraged to learn from experience and to act on what they learn.