How learning happens in health system responses and initiatives: a realist synthesis

Learning is common to all health system initiatives and responses. But health system initiatives and responses are typically named, framed, analysed, and supported in research, practice, policymaking, and advocacy, as if they are inherently different from one another. Focusing solely on labels (what they are called) or what is immediately apparent (their observable effects) misses what connects them to one another: learning. A learning approach may better inform efforts to analyse and support those health system initiatives and responses. In this realist synthesis, we synthesised insight from published articles to better understand the dynamics of learning in health system initiatives and responses. We searched five databases and included 51 articles (from 30 countries): 32 on health system strengthening, eight on innovation adoption and scale-up, and 11 on health system responses to shocks. Using a theoretical framing from organisational learning to explain low learning (mechanisms: single loop, double loop and triple loop learning) shapes the manifestations (outcomes) of health system initiatives and responses, we identified contextual conditions; three in the lead up to a response or initiative, that is, “prior” category (embeddedness, curiosity and obligation) and three during a response or initiative, that is, in the “amid” category (diversity, platform and support). This reframing advances understanding of how observable and measurable changes in health systems emerge within the socio-political structures in which they are initiated and implemented. It also provides a comprehensive framework that may guide future study and efforts to facilitate learning within health system initiatives and responses.