International Synergy: Country Pairings for Enhanced Learning and Development

About the author: Jane Nyambura serves as a Program Officer for the Joint Learning Network for Universal Health Coverage (JLN), a position she has held for the past two years. She is currently furthering her expertise by pursuing a Master of Science in Health Economics at the University of Nairobi. Jane’s role at JLN involves facilitating collaborative learning and capacity-building efforts among member countries, leveraging her growing expertise in health economics to enhance the network’s impact on universal health coverage initiatives. 

Health care systems are crucial in implementing health actions that promote population health and
Sustainable Development Goals (SDGs). However, achieving universal health coverage (UHC) is
impossible without the proper actions to strengthen health system challenges, especially in developing
countries 1.

Comparison of experiences across different countries can offer insights both from a health policy and
a health management perspective (Vest, 2012). Over the last decade, there has been growing interest
to understand why healthcare innovations that work in some country contexts do not work in others
and when and why certain implementation processes work better than others.

Healthcare systems in developing countries often face similar challenges, primarily related to
financing, accessibility, and quality of care. (Figueroa, C.A., Harrison, R., Chauhan, A. et al, 2019.)
Given the shared healthcare challenges and varying progress towards achieving universal health
coverage (UHC) among developing countries, peer-to-peer learning can be a crucial strategy. This
approach allows countries to share experiences, best practices, and lessons learned, thereby
accelerating progress and avoiding the pitfalls of reinventing the wheel.

Joint Learning Network (JLN)

The Joint Learning Network (JLN) country pairing modality is meticulously fashioned to facilitate joint
learning sessions that convene two or more interested countries on a specific topic. The explicit goal
is to exchange experiences and learn from each other, thereby accelerating progress towards
achieving Universal Health Coverage (UHC) and strengthening health systems. This approach
leverages the power of peer-to-peer learning to share best practices, lessons learned, and innovative
solutions tailored to each country’s unique context. This support complements other learning activities
and is usually embedded in a collaborative.

Cross-national comparison of data on different health systems is paramount for public policy purposes,
and the first step in such a comparison is to identify countries to be compared (Bauer & Ameringer,
2010). In line with the Joint Learning Network (JLN) country-led and country-driven approach, learning
countries express an interest in partnering with a resource country, clearly defining the learning
questions they wish to address. The technical facilitation team then arranges a virtual session (or
series of sessions) between the countries. This team also works with both country teams to mobilize
additional members who can benefit from the pairing.

The process kick starts with identification of specific health system challenges and expression of
interest by learning countries to partner and learn from a resource country that has relevant
experience. Secondly, learning countries articulate precise learning questions that guide the focus of
the sessions. These questions are designed to elicit actionable insights and practical knowledge that
can be directly applied to the learning country’s context. The questions also inform how the technical
facilitation team packages and facilitates virtual sessions, ensuring that discussions are productive
and focused on the learning objectives and questions. Finally, interactive virtual discussions are held
encouraging open dialogue and knowledge exchange between the countries.

The JLN has continuously improved and iterated on this approach to joint learning. In the most recent
grant cycle, there have been two innovative approaches the network has focused on. Both are smaller
group modalities with an intensive focus on one country’s challenges, with other countries serving as
resource countries, often alongside a technical facilitation team.

Country Pairings

Over the past five years, countries participating in the Joint Learning Network (JLN) have shared
requests and engaged in successful pairings to strengthen various health system building blocks 2.
These collaborations have focused on areas such as service delivery, health workforce, financing, and
governance. Here are some examples of these pairings:

Ghana and Kenya. Aug 2020 and Nov 2020 – Kenya learned from Ghana’s implementation of the
Primary Care Networks (PCNs) to improve access to quality health services. LN PHC financing
collaborative and country pairing with Ghana to advance Primary Healthcare Reforms in Kenya

‘Through this collaborative a peer-to-peer learning and exchange was organized through virtual meetings in June 2020 between Kenya team (Ministry of health PHC team, health financing team, NHIF and selected County teams) and Ghana PHC team. The Kenyan team learnt the nuances of how PCNs could be operationalized – the process of setting up functional PCNs, governance structures, the referral networks within and outside the PCN, the purchasing arrangements, management/ supervision, monitoring and evaluation of quality service delivery. Armed with this information, Kenyan policy makers developed guidelines for National implementation of the PCNs. Additionally, the best practices learnt from Ghana and other key learnings from the JLN PHC financing collaborative informed the PCNs implementation then in 12 counties – a journey that has currently culminated in establishment of close to 120 networks across 39 counties.’ Dr. Isabel Maina, Kenya

Mongolia and Vietnam. Indonesia. Sep 2020 – Indonesia sought insights from Mongolia and Vietnam
on strategic purchasing and provider payment mechanisms to enhance its national health insurance
program.

Mongolia and Moldova. Sep 2020 and March 2021 – Moldova developed an interest in learning
more about Mongolia’s health insurance system and their pay for performance (P4P) indicators, how
they are monitored, and the basis of calculating P4P payments. This pairing was an opportunity for
Moldova to delve deeper into utilizing and revising P4P indicators, as well as an opportunity to probe
Mongolia on best practices and lessons learned.

In the second session, the Moldova team explored more about Mongolia’s health insurance system
and costing for the diagnosis related groups (DRGs) used by the Health Insurance General
Organization (HIGO).

‘The comparison made us understand where we are and what problems we have and what to improve…Even if there is a difference between us and them we tried to revise our relative values of the DRG system. so, this made us understand in what way we should go about it. Even our relative values were revised, the first time in 2013, and then in 2019, so after this exercise with Mongolia it was revised this year (2021) but we began in 2020.‘

Ghana and Nigeria. Oct 2020 – The Nigerian team was keen to learn from Ghana’s experience on
how to promote buy-in and sustainable funding for the programme especially at sub-national level;
and to learn more about the level of acceptance and impact of the Community-Based Health
Planning and Services (CHPS) programme in Ghana. Learnings from this pairing were used to
strengthen CHIPS and develop a CHIPS strategy in Nigeria.

Ghana and Malaysia. Sept 2022 and Nov 2020 – Malaysia expressed interest to learn more from
Ghana’s development and operationalization experience with respect to changes and evolution of
Provider payment mechanism (PPM) for primary health care, with special focus on pharmaceuticals.
Two virtual sessions took place on the same topic.

Indonesia and Malaysia. April, 2023 – Indonesia sought insights from Malaysia on digital risk
Profiling on how countries develop their population risk stratification/risk profiling.

Malaysia and Ghana/Philippines. March 2023 – Ghana’s/Philippines shared insights with Malaysia
on – Medical Audit i.e. development and operationalization experience with respect to: Mechanism of
provider monitoring including the changes, evolution and lesson learnt of Medical Audit (MA)
particularly for primary healthcare services, preferably with focus on treatment for chronic noncommunicable diseases (NCDs); Mechanism and method to incentivize/ penalize providers; Mechanism to develop indicators/flags for NCD claims to assist in investigations;
4.Examples of case studies (e.g. fraud cases – method of investigation , follow up action)
JLN knowledge product: Toolkit to Develop and Strengthen Medical Audit Systems

Currently, JLN member countries have submitted additional requests on various topics, including
subnational networks, Community-Based Health Insurance (CBHI), telemedicine and primary health
care (PHC), enhancing the institutional capacity of PHC institutes, and updating Health Benefit
Packages (HBP). These requests are currently in the inception phase.

Challenges and Next Steps

Despite the recorded successes this cross country, peer to peer approach offers for advancing
Universal Health Coverage (UHC), several challenges persist which can be attributed to JLN diverse
membership distributed across Africa, Middle Eastern Region, South-East Asia, South Asia, Eastern
and Europe Latin America.

The diversity in membership thus encapsulates various challenges, including diverse health system
contexts, political and governance barriers such as political will and stability, governance structures,
resource constraints, information and knowledge management, coordination and collaboration
challenges, monitoring and evaluation for measuring impact, adaptation and feedback mechanisms,
and ensuring sustainability and scalability.

To overcome these challenges, countries engaged in peer-to-peer learning for UHC should emphasize
building strong, adaptable frameworks that allow for contextualization of shared strategies, investing
in data and knowledge management systems, fostering political and institutional commitment, and
ensuring ongoing evaluation and adaptation of initiatives.

Key best practices recorded by the Joint Learning Network highlight the importance of various
strategies, particularly in the post-COVID era. One of the most crucial practices is adopting a
“capstone” approach to structuring collaborative learning exchanges. This approach involves starting
and ending with an in-person event to build stronger networks and social ties among country members,
while conducting intermediary sessions virtually. This ensures robust relationship-building and
seamless virtual engagement. More lessons can be found 6. here.

References

1. Bulletin of the World Health Organization (who.int)
2. Bauer, D. T., & Ameringer, C. F. (2010). A framework for identifying similarities among countries
   to improve cross-national comparisons of health systems. Health & Place, 16, 1129- 1135.
3. Burau, V., & Blank, R. H. (2006). Comparing health policy: An assessment of typologies of health
   systems. Journal of Comparative Policy Analysis, 8, 63-76.
4. Figueroa, C.A., Harrison, R., Chauhan, A. et al. Priorities and challenges for health leadership and
   workforce management globally: a rapid review. BMC Health Serv Res 19, 239 (2019).
   https://doi.org/10.1186/s12913-019-4080-7
5. Greenhalgh, T., Robert, G., Macfarlane, F., Bater, P., & Kyriakidou, O. (2004). Diffusion of
   innovations in service organizations: Systematic review and recommendations. Milbank Quarterly,
   82, 581-629.
6. PHC-FP-Country-Pairing-Evaluation-Report-Final.pdf (jointlearningnetwork.org)
7. Vest, J. R., Zhao, H., Jasperson, J., Gamm, L. D., & Ohsfeldt, R. L. (2011). Factors motivating
   and affecting health information exchange usage. Journal of American Medical Informatics
   Association, 18, 143-149.
8. World Health Organization (WHO). Everybody’s business – strengthening health systems to
   improve health outcomes: WHO’s framework for action. WHO; Geneva:
9. http://www.who.int/healthsystems/strategy/everybodys_business.pdf