Table 2 PPA workshop activities details, objectives and processes

River of Life (RoL)

An art-based autobiographical mapping (reflective) tool that encourages group members’ bonding, RoL uses the metaphor of river to depict a personal journey or history as well as future aspirations. River bends, width and discontinuities represent the junctures, breadth of perspectives, events and pauses that have occurred during the life course. RoL can be used alongside other approaches to explore particular issues and problems [28, 32] and is especially useful for understanding change over time

(a) Get each participant thinking about federalism and its impact on the health system and their working lives

(b) Understand the impacts of federalism on health system stakeholders’ working lives

(c) Explore stakeholders’ perceptions of how the health system, their journey and experiences in the health sector have changed over time (focus on before and after federalization)

Participants sketched on large chart paper the “flow” of their working lives and their interaction with the health system, with a focus on changes that have resulted due to federalism

They then presented their “rivers” to the other participants in the workshop

Brainstorming and Prioritization

Brainstorming—a creative thinking process—is the most common and well-known technique for ideation, increasing creative efficacy or for finding solutions to problems. It can be conducted as an individual or group exercise.

Prioritization involves collaborative discussion to prioritise issues that have arisen through the brainstorming based on their perceived order of importance. While brainstorming is a divergent phase aiming for quantity (numbers of ideas/issues), prioritizing is the convergent phase where there is sorting of the ideas/issues identified to find those that are judged to be most crucial [33,34,35,36]

(a) Get participants thinking about the full range of problems and challenges brought about by federalization, and how those problems have affected the health system  and/or their own working lives

(b) Collaboratively prioritise federalization-related policy/programme issues

Participants were grouped into random groups using the chit method. Each group brainstormed as many problems/issues as possible. This was followed by rigorous discussion in groups to prioritise the identified problems. Participants considered issues that they felt were creating significant impacts on the health system and/or their own working lives

Problem Tree

A “tree” diagram showing the cause–effect relationship between problem conditions in a defined context. Problem tree analysis thus involves working through a defined problem to map out the cause and effect surrounding the problem, which in turn leads to finding/ investigating solutions, either through tackling root causes or seeking to mitigate effects. By allowing the prioritized problem to be broken down into manageable and definable chunks, it enables clear understanding of the problems and its often interconnected and sometimes contradictory causes [37, 38]

(a) Collaboratively create a “problem tree” – to identify root causes and consequences of the group’s chosen problem (identified in the previous stage)

(b) Work together to develop relevant policy or practice suggestions to resolve the problem or mitigate its effects

Each group collaboratively developed a problem tree for the key problem they identified in the brainstorming and prioritization session. The problem was represented by the trunk of the tree, the multiple causes of the problems as roots and the consequences – small and large – as branches of the tree. The problem analysis was followed by group discussion of possible solutions/ mitigations (at a practice and policy level)