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Table 1 Core learning site activities

From: Learning sites for health system governance in Kenya and South Africa: reflecting on our experience

  Kilifi Mitchell’s Plain Sedibeng
Initial research proposal (focus and activities) Proposed a traditional but quite broad research project addressing the functioning of planning, management and accountability processes in the district (county). The science/ethics proposal included data collection through observation, document review and interviews, also allowing for reflection on research findings and identification of additional specific case studies with managers; therefore, the proposal enabled the research team to have increasing flexibility in responding to emerging, manager-informed questions Proposed an action learning process involving researchers working with local health managers and staff to (1) consider local needs and opportunities; (2) identify key entry points through which to strengthen the district health system (considering planning, leadership, management and monitoring processes, concern for community engagement, inter-sectoral engagement); repeated cycles of planning, implementation/ practice, reflection and evaluation, learning, and revision were outlined in the science/ethics protocol, with data collection through observation, document review, interviews and reflective practice discussions Proposed an action learning process involving district health managers and researchers; included traditional research activities to learn about district planning, management and accountability processes (including, specifically, staff performance management) and daily challenges involving interviews, document review and observations; the science/ethics protocol also allowed for feedback to district managers and collective reflection to generate new rounds of activities
Subsequent activities As our learning evolved, a second science/ethics protocol focused more broadly on the micro-practices of governance at sub-national level (county, sub-county and facility level), considering leadership practices, organisational relationships and their underpinning values; additional research foci included programme-based budgeting, facility financing and the participatory development of a leadership intervention
Cycles of reflection and planning with managers remained the core research approach.
Annual cycles of action, learning and reflection continued over time in line with the original protocol
Specific sub-studies were also developed with their own research protocols, where they entailed engagement with a new set of respondents or a new data collection approach (e.g. inquiry into primary healthcare facility managers’ experiences involving journaling [10])
Over time, the annual cycles of action and learning also included support for managerially led interventions focused on management processes and leadership development interventions
Based on earlier learning, a second science/ethics protocol focused on initiating and conducting monthly leadership support intervention workshops with senior and middle level managers, with the support of an external facilitator; this was accompanied by traditional research activities such as diaries and observations to understand and track experience over time
The most recent phase of work across sites was guided by a shared umbrella proposal, supporting us to test our emerging insights into everyday resilience [28] across sites using a common conceptual framework, with activities adapted to each site as appropriate
Cycles of reflection among researchers Reflection meetings were held every 1–4 months, with more regular discussions in busy data collection periods;
in meetings, de-brief on learning across a series of sub-areas of interest; share information on cross-cutting contextual issues and observations; share theoretical and empirical work to assist analysis; discuss strategies for engagement with managers, reflecting on our varied expertise and experience; specific sessions were dedicated to ethical dilemmas in response to experience
Regular reflection meetings were held monthly in the initial years and, subsequently, around every quarter or more frequently as activities required; these meetings included
de-briefing on observations and engagements in the learning site; discussion of ethical dilemmas; review of relevant theoretical and conceptual work to assist analysis; identifying and reviewing emerging insights from analysis; planning further activities
Regular reflection meetings were conducted monthly, including to de-brief on engagement and emerging developments in the learning site and to generate potential strategies to manage emergent developments (such as ethical dilemmas);
during the second phase, meetings were held prior to and after each leadership intervention workshop throughout the intervention cycle
Cycles of reflection with managers Once/twice a year, formal reflection meetings were held to allow feedback of emerging findings and their discussion as well as to identify key priorities and interests moving forwards;
regular informal, continuous interactions between researchers and core managers, to track contextual issues and co-produce research outputs
Annual reflection meetings held to feed back on work conducted and insights generated as well as to identify next steps of research and other new activities
Regular informal and continuous discussions with core managers to track developments and activities within the site as well as around co-production of research outputs
Initially, regular informal discussions with district manager to brief and clarify emerging findings and developments, and to identify key areas to address in new activities;
subsequently, de-briefing discussions with district manager at key points of the leadership intervention to reflect on developments and the ongoing activities within the site
External sounding boards and concern for ethics Annual reporting process to check science and ethics across sites involving external actors; in addition, responding to emerging concerns, two ethics reflection sessions were organised at annual RESYST meetings to support one another in ensuring ethics in practice in each site (see also [39])