Table 3 Limitations of learning by stage and by blocks of learning

Agenda-setting and policy formulation

• Continued influence of the hierarchical structure of public administration

• Sometimes a top-down approach in decisions

• Difficulty in expressing all the points of view

• Learning more at the individual level with weak organisational learning

• The sharing was not for all aspects (some retention among departments)

• Practical processes were not systematised

• Most developed knowledge was tacit

• The learning agenda was episodic and ephemeral, and not integrated into the routine of organisations

• Problems storing the knowledge for further use

Policy implementation

• Weak autonomy of hospital directors

• Lack of resources to encourage learning at the local level

• Continued influence of the hierarchical structure of the public administration

• Weak integrated information system

• Weak sharing with other departments at regional level

• People were not reassured enough to express their opinion regarding the design of guidelines and regulations

• Openness to expressing ideas depended on the profile of the manager

• There were overlapping roles of entities involved in RAMED (conflicts)

• Learning processes were quite ephemeral

• Unshared reports (lack of platforms for sharing)

• The practical processes of learning were not systematic (lack of systematic knowledge management strategy)

Policy evaluation

• The Ministry of Finance did not adopt the recommendations of the evaluation to increase resources for health

• Participation in the evaluation was limited to a few persons from the Ministry of Health, not a large participation in the discussion of recommendations

• Weak translation of the evaluation’s recommendation to action in the field for the implementation of RAMED