The purpose of this paper is to present a case study of the World Health Organization’s Global Healthcare Workforce Alliance (GHWA). Based on a commissioned evaluation of GHWA, it applies network theory and key concepts from systems thinking to explore network emergence, effectiveness, and evolution to over a ten-year period. The research was designed to provide high-level strategic guidance for further evolution of global governance in human resources for health (HRH).
Methods included a review of published literature on HRH governance and current practice in the field and an in-depth case study whose main data sources were relevant GHWA background documents and key informant interviews with GHWA leaders, staff, and stakeholders. Sampling was purposive and at a senior level, focusing on board members, executive directors, funders, and academics. Data were analyzed thematically with reference to systems theory and Shiffman’s theory of network development.
Five key lessons emerged: effective management and leadership are critical; networks need to balance “tight” and “loose” approaches to their structure and processes; an active communication strategy is key to create and maintain support; the goals, priorities, and membership must be carefully focused; and the network needs to support shared measurement of progress on agreed-upon goals. Shiffman’s middle-range network theory is a useful tool when guided by the principles of complex systems that illuminate dynamic situations and shifting interests as global alliances evolve.
This study was implemented at the end of the ten-year funding cycle. A more continuous evaluation throughout the term would have provided richer understanding of issues. Experience and perspectives at the country level were not assessed.
Design and management of large, complex networks requires ongoing attention to key issues like leadership, and flexible structures and processes to accommodate the dynamic reality of these networks.
This case study builds on growing interest in the role of networks to foster large-scale change. The particular value rests on the longitudinal perspective on the evolution of a large, complex global network, and the use of theory to guide understanding.
Best, A., Berland, A., Greenhalgh, T., Bourgeault, I., Saul, J. and Barker, B. (2018), "Networks as systems", Journal of Health Organization and Management, Vol. 32 No. 1, pp. 9-24. https://doi.org/10.1108/JHOM-06-2017-0129Download as .RIS
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Copyright © 2018, Emerald Publishing Limited
In 2006, with funding from international donors, the Global Healthcare Workforce Alliance (GHWA) was created with a ten-year mandate. The new organization was governed by a board representing its diverse member base of human resources for health (HRH) experts and practitioners (www.who.int/workforcealliance/about/en/). Operations were managed by a secretariat hosted by the World Health Organization (WHO). Historically, discussions about global HRH issues focused largely on increasing resources to fill staff deficits (Dussault, 2015), taking a relatively simplistic approach to a complex problem. Tackling issue characteristics as varied as recruitment and retention, scope of practice, technological change and mobility requires the coordinated engagement of many sectors. This broader perspective emerged in 2004 when the Joint Learning Initiative asserted that many countries would not meet their Millennium Development Goals due to what the report termed, “the HRH crisis”(Joint Learning Initiative, 2004a). International concern was further focused by the WHO report “Working Together for Health”, which proposed a global alliance of stakeholders to advocate for resources to develop HRH (World Health Organization, 2006).
Over a decade, GHWA’s Board developed a global network involving hundreds of HRH stakeholders. As a convener, the Alliance hosted three global fora resulting in international declarations and political commitments to address HRH in low- and middle-income countries (LMIC’s). Seeking to act as a catalyst for change, GHWA organized and produced planning tools and resources to support the evolving discourse on ever-changing HRH needs and environment among policymakers and other stakeholders.
In addition to its many important accomplishments, GHWA also encountered significant challenges. By the end of its lifespan, GHWA was judged by some stakeholders as having failed to meet (admittedly vague) expectations.
The past decade also has seen a growing understanding among global health leaders that many of the priority challenges truly are complex (Best and Holmes, 2010; Best et al., 2007; Herbert and Best, 2011). Adam and de Savigny (2012) followed their publication for the WHO Alliance for Health Policy and Systems Research Flagship Report “Systems Thinking for Health Systems Strengthening” (2009) with a special issue in Health Policy and Planning. The supplement highlighted the evolution in thinking about how to improve health systems in LMIC’s.
The Flagship Report’s model for systems thinking underscores the importance of integrated strategy that addresses six cornerstones and their interactions: governance; human resources; finance; information; medicines and technologies; and service delivery. The Flagship Report and special issue highlight key principles of complex systems that affect strategy development and system strengthening for issues like innovation, collaboration and learning, training, measurement and feedback, and network development (Adam and de Savigny, 2012; Atun, 2012; Swanson et al., 2012; Willis et al., 2012). The report highlights some of the critical characteristics of health systems and the need for a paradigm shift “from linear, reductionist approaches to dynamic and holistic approaches that appreciate the multifaceted and interconnected relationships among health system components, as well as the views, interests and power of its different actors and stakeholders” (Adam and de Savigny, 2012).
To inform this analysis, we applied Shiffman et al.’s (2016) theory of network emergence (Figure 1) on the emergence and effectiveness of global health networks. According to this framework, issue characteristics (e.g. HRH shortages and related framing strategies) continually interact with network and actor features (characteristics of, and relationships between individuals and organizations in the network), as well as the policy environment (measurement systems or accountability structures), resulting in network emergence and effectiveness.
The GWHA study explores a cross-cutting network concerned with HRH strategy across numerous content areas including vertical programs (e.g. disease-specific initiatives) and horizontal (i.e. national) programs. This analysis considers GHWA’s evolution as a network over ten years, complementing Shiffman’s focus on emergence and effectiveness. To aid our theoretical analysis, we also drew upon a number of the case studies in the 2016 special issue of Health Policy and Planning that focused on international health networks (Shiffman et al., 2016).
The analysis extends the set of factors included in the Shiffman et al.’s (2016) framework to explore leadership as well as the role of power and context in unexpected events. There is a particular focus on one network function – that of the network administration office – which (for the purposes of this analysis) we took to include convening, acting as a catalyst for change, and provision of tools and resources. In the discussion section, we present key recommendations for the next phase of global HRH governance.
Methods included a review of published literature on HRH governance and current practice in the field and an in-depth case study whose main data sources were relevant GHWA background documents and key informant interviews with GHWA leaders, staff, and stakeholders. Sampling was purposive and at a senior level, focusing on board members, executive directors, funders and academics. Data were analyzed thematically with reference to systems theory and Shiffman’s theory of network development.
Review of published literature
The research questions guiding the literature review were:
What is the state of global HRH governance?
How does GHWA fit into the wider HRH governance landscape?
Actor analysis: Which stakeholders have been involved in developing international HRH policy?
What is the nature of their relationships, how do they change over time, and how does their access to resources vary?
What impact has GHWA had on HRH?
What are the measures of success for GHWA and how have impacts of its activities been determined?
Time and resource constraints dictated a strategic search process, initially with guidance from GHWA staff and our expert panel, followed by keyword searches of indexed databases, to identify key articles. In total, 65 articles were considered, both academic (i.e. peer-reviewed) and non-academic (e.g. government and NGO reports, grey literature). Articles were excluded if their abstracts did not mention HRH or governance or focused too narrowly on a specific occupation or country. In total, 15 publications met inclusion criteria and were fully reviewed and extracted using a template developed to help answer the research questions. Key article references were mined for additional sources from which nine additional articles were identified for a total of 24 sources.
Review of background GHWA documents
The research questions for the background document review were:
How was GHWA conceived? What were its goals at the outset? What rationale was provided?
What model has GHWA used for HRH governance?
What were the major milestones in terms of activity?
What has worked in particular contexts and what has not?
How has GHWA’s original plan changed over time (and why)?
What is the impact of GHWA globally, locally and regionally?
To deepen our understanding of GHWA’s history, we catalogued over 700 documents from the GHWA website. Titles and descriptions of each were categorized, reviewed, and prioritized based on their relevance regarding the research questions. Data from the 27 documents most relevant to our research questions were synthesized to guide the key informant interviews.
Key informant interviews
In total, 23 individuals from a list of 26 provided by GHWA staff were interviewed over a four-week period in late 2015. They included current and former GHWA Board members and executive directors, as well as funders, academics and other global HRH stakeholders who had participated in GHWA activities. The interview protocol included questions about GHWA’s legacy and impact on advancing global HRH governance. Interview responses were analyzed thematically to identify recurrent themes and observations. Early findings and “hunches” were discussed with GHWA Board members as part of a regular meeting of the Board.
Interviews were audiotaped and transcribed. Thematic analysis was used for both secondary sources (published literature) and primary sources (documents and interview transcripts). As we applied Shiffman’s theoretical model of network emergence, we were prompted to return to the original data sources to explore selected themes in more depth. Narrative synthesis was used to craft a historical account of GHWA’s evolution, attempting to identify how external forces and critical success factors changed over time, taking account of the components within Shiffman’s model. This over-arching narrative was enriched iteratively as successive sources were added to the account.
To ensure consistency and to minimize the risk of bias from any resource type, we triangulated our findings from the literature review, background document review, and key informant interviews.
Results are presented using the Shiffman et al.’s framework to explain how the mechanisms of network development interacted with other influences in a dynamic context. Arrows between key components or spheres of the framework (Figure 1) represent the constant, multiple, and dynamic interactions that appeared to contribute to the emergence and effectiveness of GHWA. Whilst we have attempted to identify achievements that could be fairly confidently attributed to GHWA efforts, many other organizations also contributed to the changes during this period.
Building a global network of diverse actors
Governed by a multi-sectoral board, GHWA engaged over 400 members from national governments, international development agencies and banks, academia, and civil society groups including professional organizations. Significantly, GHWA reached beyond traditional health service stakeholders to include aid donors as well as private not-for-profit groups, although it was less successful in engaging for-profit private sector interest.
According to Provan and Kenis (2008), goal-oriented networks such as GHWA require greater structural stability to ensure participants engage in mutually supportive activities, address conflicts, and use resources efficiently. GHWA benefitted from such a relatively stable structure with a well-defined mandate including clear work plans, a representative governing Board, a secretariat hosted by the WHO, reasonable operating resources, and regular meetings and communications. This was particularly appropriate at the outset, considering the number of network members, the complexity of the issues and the lack of consensus regarding network goals (Provan and Kenis, 2008).
Our key informants cited specific activities as evidence of GHWA’s success in convening actors both within and separate from pre-existing networks. For instance, three global fora were organized, resulting in significant political commitments to both policies and improvement of resources. Key informants noted that GHWA was the only organization that could have convened these well-attended fora of diverse stakeholders. Other agencies were perceived by our informants as lacking the mandate or trust, a critical element in effective network development (Provan and Kenis, 2008). One informant commented: “We learned that it is possible to create a broad movement that allows participants to set their own local and regional priorities […] [and] that these regional efforts may be the most appropriate level to develop implementation strategies. The ‘centre’ (sic) can frame the issues but not drive the change.”
Emerging understanding of complexity as a critical issue
According to Shiffman’s framework, issue characteristics include how topics are framed as the basis for a common agenda. One of GHWA’s key achievements was its ability to shape dialogue on HRH issues. Each of its fora resulted in significant policy statements that framed a response to causative factors of HRH shortages. The Kampala Declaration from the first forum highlighted the need for all stakeholders to address the HRH crisis through an “Agenda for Action” (World Health Organization, 2008). A key outcome of the second forum in Bangkok (2011) was a critique of progress since the first forum and a recommendation for follow-up work to achieve the goals of the Agenda for Action. At the third forum (2013), the Recife Declaration set the stage for countries to accept accountability for taking action to address their national HRH issues.
Despite its success in convening three fora that helped shape consensus and motivation for ground-breaking initiatives, GHWA’s ability to maintain a consistent, governance-level agenda remained a challenge. One limitation, according to some key informants, was allowing Board members to participate with independent voices rather than as agents or representatives of their organizations. Some Board members were perceived as representing their own personal views, rather than speaking on behalf of their respective organizations. At times this disconnect hindered development of a common platform by the participating organizations. Key informants observed that active board membership and engagement is essential to the effectiveness of an organization like GHWA. According to one key informant: “Governance matters, and if a board is somehow able to pull on its networks and link people who want to [achieve] this agenda, then things will move forward.” Other informants ventured that the effectiveness of the GHWA Board in support of the Alliance’s agenda became weaker over time partly because of its failure fully to engage its networks.
Key informants generally agreed that GHWA’s two greatest contributions to global HRH governance are first, the introduction of systems thinking and planning about HRH issues; and second, the development of network learning and competencies that will be the foundation for the next iteration of global HRH efforts. Evident as this now appears, GHWA’s pioneering efforts raised initial awareness of the systemic nature of the HRH crisis among various stakeholder groups, at both national and international levels. Here again, GHWA’s efforts were instrumental and also illustrates the evolving reach of its network: the initial focus on crisis countries evolved to include LMIC’s, then shifted further to bring high-income countries to the table. As described in the next paragraph, development of the WHO Code initiated thinking about HRH as not only an LMIC issue. Among many examples of its impact, for instance, GHWA’s influence prompted inclusion of HRH-specific language and targets in the UN’s Global Strategy for Women’s and Children’s Health. Additionally, key informants also noted the importance of linking previously isolated or unengaged stakeholders, in particular from development finance and disease-based programs, which may impose unexpected strains on national HRH systems. Moreover, the systems perspective demonstrated that achieving Universal Health Coverage and Sustainable Development Goals would require an “investment platform” to deliver a comprehensive approach to HRH development.
A dynamic policy environment
As noted, GHWA’s first global forum resulted in the Kampala Declaration. This forum also reignited momentum for a “WHO Global Code of Practice on the International Recruitment of Health Personnel,” later adopted by the World Health Assembly (Dayrit et al., 2008). This very significant achievement indicated that high-income countries recognized not only the complexity of their own HRH issues but also their potential to undermine national health system development in LMIC’s (McCoy et al., 2008).
Over GHWA’s decade of existence, the policy environment changed significantly. The financial events of 2008 triggered not only budget pressures for WHO and national governments, but also retrenchment from international initiatives. Coincidentally, the need for both a common agenda between global funders and local actors, and mutually reinforcing activities, is reflected in the literature on HRH governance, which emphasizes local applicability (Brown, 2014; Dieleman et al., 2011; Lavis et al., 2005). Without attention to local contexts and capacities, HRH plans may have little impact (Dussault, 2015). GHWA tackled this significant challenge head on with several programs that helped strengthen capacity within applied areas: extensive work on tasks and roles of mid-level and community-based health practitioners; building the Health Workforce Advocacy Initiative to link civil society initiatives; and supporting HRH aspects of various “vertical” programs that targeted specific health issues such as HIV-AIDS.
At the second GHWA forum in 2011, participants identified a lack of reliable and comparable national HRH data. They recommended routine collection, collation, analysis, and sharing of country-level data to inform planning and management. In addition, participants called for new benchmarks for monitoring and evaluation that would consider more variables than national per capita densities of health workers (Global Health Workforce Alliance, 2011). This reflects the emerging conceptualization of HRH as a complex systems problem. The GHWA Board recognized that effective networks should include shared measurement systems (Kania and Kramer, 2011). Unfortunately, these shifting measures may have also contributed over time to perceptions that GHWA failed to meet expectations. That is, we heard mixed reviews about GHWA’s repository of analyses, reports, and tools. An external evaluation found these resources were high quality and influential at a global level, but largely unknown by intended end-users at the national level (Vaughan et al., 2011). Additionally, some key informants thought this work was duplicative of other, better repositories.
The third global forum in 2013 is a further example of GHWA’s ability to influence the policy environment (Global Health Workforce Alliance, 2013). Participants issued another call for action in the Recife Political Declaration on HRH which was similar to previous forum statements including the recommendations of “Working Together for Health” (World Health Organization, 2006) and the report of the Joint Learning Initiative (2004b). National governments and NGOs issued public commitments to their own HRH goals – a major accomplishment since it required accepting accountability for improvement. Forum attendees recommended that WHO develop what later became its “Global Strategy on HRH: Workforce 2030” (World Health Organization, 2015). Following this, GHWA led an inclusive and participatory process to analyze current thinking, especially the emerging initiatives framed by the Universal Health Care concept, with GHWA playing a key role in synthesizing the evidence base for WHO’s Workforce 2030 strategy.
Dynamic interplay of network and actor, issue, and policy factors
Not every attempt by GHWA to influence global HRH strategies was successful. Within the policy environment, WHO coordinates global health diplomacy through negotiation and support (Renganathan, 2013); whereas GHWA acted as a convenor, knowledge broker, and advocate to raise political awareness and catalyze action. At times, the different roles of WHO and GHWA became confused. An example of the challenges in tackling complexity is the planning model developed by GHWA to assist HRH development at the country level. In GHWA’s early days, members’ initial enthusiasm led to rapid growth of the network with productive engagement on several initiatives. After the first global forum, however, conflict arose between GHWA and WHO, partly due to budget pressures from the global economic crisis. Recognizing the need to focus its systems perspective on actionable issues, the GHWA Board concentrated on the national HRH context. The resulting Country Coordination and Facilitation Framework (CCFF) provided guidance for inter-sectoral and multi-constituency collaboration to accelerate the implementation of a country’s HRH agenda, based on core principles (Global Health Workforce Alliance, 2010).
Several key informants regarded GHWA’s CCFF work as a major contribution, noting that where it was applied, the CCFF process brought together diverse participants within each country, often including hard-to-reach political leaders and important supporters, such as staff from Ministry of Finance. However, we also heard that some stakeholders accused GHWA of going outside its original mandate with its CCFF, intruding in the realm of national governments, and leading to a lack of alignment and cohesiveness within the Board. This also created significant friction with WHO, which felt GHWA was intruding on WHO’s sphere of influence. Contextualizing this, one key informant commented, “[…] these are issues that WHO HR department should be looking at […] HR was too headquarter-centric so there was a gap in support to countries.” Clearly, these network and actor features pose a difficult balance to negotiate.
The 2008-2012 period during which GHWA worked to implement its CCFF was widely viewed by our key informants as the low point in its history. Causes were both externally and internally driven. With its CCFF activity, the GHWA Board appears to have been trying to provide structural stability, focused action and practical opportunities for shared learning. Unfortunately, this created a widespread perception that GHWA leadership was politically insensitive about role boundaries. Key informants identified situational factors such as budget pressures and territoriality within WHO as aggravating factors but were particularly critical of GHWA leaders’ communication styles, both in managing the policy relationship with WHO and in engaging network members around a coherent vision of GHWA’s role. To address the significant tension with WHO, involving both actor and issue features, the GHWA Board subsequently refocused its role, strengthened its advocacy and convening functions through the global fora and avoided the troublesome boundary issues. Paradoxically, despite the credibility issues arising from the implementation process, the CCFF was viewed by many of our key informants as one of GHWA’s most significant achievements. Moreover, the CCFF methodology appears to have been useful, with external evaluation and GHWA’s analysis of CCFF usage showing positive outcomes for several countries (Global Health Workforce Alliance, 2012a, b; Vaughan et al., 2011).
Network evolution in response to environmental pressures
By late 2011, halfway through its ten-year mandate, a mid-term evaluation noted GHWA’s strengths in advocacy and convening, the success of its global fora, and its ability to work at global, regional, and country levels (Vaughan et al., 2011). Weaknesses identified by the evaluation included the secretariat management style; advocacy that was too focused on the deficit in numbers of health workers in developing countries; and lack of innovation in renewing the Alliance’s objectives over time. The evaluators identified potential challenges for GHWA including emergence of new global and regional HRH organizations, increasing competition for donor funds, and GHWA’s reduced credibility to lead.
The GHWA Board responded to the evaluators’ findings with transformed objectives and a better balance among network, issue, and policy factors. These prioritized areas of work where an alliance has comparative strength such as its inter-sectoral membership representing strategic constituencies. The Board also developed a different business model, with a greater emphasis on results and specific accountability of the members and partners – an approach consistent with the principles of complex systems (minimum specification from the center; autonomy devolved to local actors). As a result of this stronger strategic focus, the friction with WHO lessened. Since 2008, financial problems have been particularly challenging due to both the global economic downturn and WHO’s budget difficulties. As one key informant stated, “GHWA has often had to spend quite a lot of time trying to mobilize funding, which can be a distraction from the actual job of doing something about the workforce crisis.” According to key informants, financial problems ultimately led to a decision not to extend the GHWA mandate.
Summing up, our key informants were consistent in recognizing GHWA’s effectiveness in the areas of advocacy and convening. There were mixed opinions about its effectiveness as a knowledge broker – although for some this function was well served by the three global fora. GHWA successfully integrated all three elements of Shiffman’s model – issues, policies, and networks – across such diverse HRH issues as training, retention, skill mix, and labor markets. As expressed by one key informant, “GHWA fundamentally changed the policy framework in the health sector. It shifted policy and then enabled it to move into practice.”
This review has produced a rich narrative of the activities and impacts of a single international network that operated over a ten-year period. The conceptual framework we used helped to elucidate and tease apart the strengths and weaknesses of GHWA’s experience. Our findings affirm the general principles common to complex systems and suggest refinement of Shiffman’s theory with several more specific principles for network evolution in such systems. Given that these principles have been drawn from a single case study, further research is needed to examine the extent to which they may be generalized. Our research study included recommendations to GHWA regarding next steps in supporting global HRH initiatives, based on the notion of a new HRH network consisting of a central “hub” hosted by WHO, that would link with and synthesize efforts of independent satellite networks (e.g. satellites focused on unique topics such as pre-service training, migration, or benchmarks).
Recommendations for the next stage of global HRH governance
Effective management and leadership are both critical
This was the main message we heard from many key informants, particularly regarding the difficulties during GHWA’s middle stage. Greenhalgh et al. (2016) provided a literature review and case study of co-creation in community-based health services that underscored the critical role of leadership in achieving research impact. Consistent with the co-creation perspective, as systems become more complex, leaders need to rely more on facilitation and empowerment, self-organizing structures, participatory action, transparency and continuous evaluation (Saul, Noel and Best, 2014; Saul, Best and Noel, 2014). As Iles and Sutherland (2001) suggest, leaders must model openness, risk taking and reflection to build and communicate a compelling vision, while providing the support needed to lead others toward it. The dysfunction key informants described of GHWA’s middle years left some with strong negative feelings. Such tension should not be unexpected as it is a persistent problem in the context of a CAS (Bowser et al., 2014; McCoy et al., 2008; Vujicic et al., 2012). Based on key informant insights, we could add to the comment by Shiffman et al.: “Things quite easily could have turned out differently” … with different leadership.
Organizational culture affects leaders’ ability to act (Willis et al., 2016). Key informants noted that GHWA exhibited more flexibility than was feasible or comfortable for WHO, highlighting the tension between formal governance and co-creation perspectives. Looking ahead, they voiced concerns that effective leadership of a network hub supported by WHO may be constrained by overly bureaucratic processes. This concern may be superseded given WHO’s evolving governance mechanisms for hosted partnerships since 2011, but remains a concern in some constituencies.
Balancing the “softer” leadership skills, our key informants also noted that any attempt to create a new HRH network to succeed GHWA would require strong administrative capacity, for instance to coordinate roles and relationships. GHWA played a critical role as a “backbone support organization,” a contribution highlighted in the literature on networks (Kania and Kramer, 2011). Key informants clearly expected that despite any resource mobilization challenges, any new network organization should have sufficient budget to fulfill its role and achieve impact. Effective management refers to establishing network structures such as working groups with clear role expectations and support; priority setting based on a shared vision and common agendas; plus, processes to facilitate rapid and comprehensive information-sharing and learning within constantly evolving actor, policy and issue environments. Without adequate staff time to construct and apply focused communications, such feedback mechanisms can result in information overload. The feedback mechanisms work best if user-friendly and well aligned with accountability mechanisms.
Balance “tight” and “loose” approaches to structure and processes of the central hub
Obviously, network success is not determined solely by a formal governance model. The effectiveness of any network model varies according to where and how densely trust is located within the network; its size; consensus on strategic goals; and the nature of the task (Provan and Kenis, 2008; Shiffman, 2007). Ferlie et al. (2010) identify such key influencing factors as inclusiveness and engagement of stakeholders, shared learning, and capacity for innovation and change. Over time, simple projects create trust and capacity for more complex endeavors (Provan and Kenis, 2008). We recommend that any new network relationships should be built iteratively using insights from a co-creation framework, with frequent and structured opportunities for trust-building, learning and self-assessment (Holmes et al., 2017).
At the same time, too much flexibility creates the risk of messy and inconclusive processes. The challenge is that as networks become more complex, demand can be expected to increase for a network’s central hub to provide structure and direction (Provan and Kenis, 2008). There are established and mandatory WHO procedures for operating networks: these are more flexible than those that govern formal partnerships, but the challenge will be in communicating these norms effectively, and in how partners adapt to them. Early in its mandate, a new HRH network would need to develop an architecture that is appropriate for a global, inter-sectoral governance network. This includes the constitution of satellite networks including common and specific purposes and roles, adequate platforms supporting their work, financial stability and distribution of responsibility. Yet at the same time, central orchestration around larger themes will need to create opportunities for stakeholders to pursue their own goals through local innovation, recognizing contextualized priorities and capacity. Following on the GHWA experience, the central hub will need to strengthen participants’ collective orientation including communication to and from their home agency. One key informant expressed concern that limited financial resources for a central hub would reduce its ability to influence the agendas of some of the satellite hubs or to maintain pressure for results. Another urged that central hub oversight must ensure at least some priorities and strategies are linked across the satellite hubs, because civil society groups may lack resources to balance the influence of wealthier groups.
Use a vigorous communications strategy to create and maintain support for the central hub
Evaluation of GHWA’s performance was outside the scope of our review, but perceptions of effectiveness deserve comment. As always, perceptions matter greatly due to the highly contextualized interplay between results, expectations and communications. Overall, despite GHWA’s many achievements as cited in the mid-term evaluation, several key informants felt it did not perform to its potential and did not achieve notable impact “on the ground.” One view holds that regional alliances of network members were not strong enough to influence high-level decision makers, or to engage stakeholders outside the health sector. This perception gap is not easy to explain. On the one hand, it should not be a surprise: as noted by some key informants, training programs and policy initiatives take many years to yield results. It should also be noted that GHWA spent an infinitesimal portion of the annual global spend on health care, and a fraction of what was thought to be required to achieve its original mandate. On the other hand, GHWA did spend $50 million over its ten-year term, so the expectation that it should have had some impact is not unreasonable. How can these conflicting views be balanced? Some key informants noted a possible factor contributing to the perception of GHWA’s insufficient impact was the deterioration in communications from GHWA to its members over time. As an example, a critical factor not adequately known by external stakeholders was the dramatic decline in availability of financial resources following withdrawal of a major sponsor in 2011. Hardly a subject to be trumpeted in a quarterly newsletter, this was nonetheless a significant challenge. Better communicated, this could have helped network members adjust expectations and subsequent perceptions of progress. Going forward, it is important to accept the importance of perceptions – justified or not – especially when political leadership and national support for investments in HRH can change quickly. To avoid similar issues, the central hub will need sophisticated, coordinated communications expertise delivering timely, relevant messages within and beyond its networks.
Focus goals, priorities, and membership for the central hub
Issue characteristics and the policy environment are closely intertwined and evolving. For instance, competition for scarce funding requires alignment with decision makers’ priorities, especially since research evidence is only one of many elements in the policymaking process. This uncertain environment is typical for networks operating in a complex system, where strategic management requires a mix of loose and tight approaches. Progress requires maintaining a clear view of broad strategic goals, carefully selecting from the range of implementation approaches and responding nimbly to evolving situations with consistent management grip.
First, it will be critical to focus on the central hub’s purpose or mission. Despite valuing GHWA’s system perspective, some key informants felt it made the agenda unmanageably large – including issues ranging from high-level policy dialog to technical details – and thus difficult to prioritize. Whereas all our key informants valued GHWA’s advocacy and convening activities, not all saw added value from the CCFF and knowledge brokering. In the future, resources will be even more constrained so focused priority setting will be critical. Key informants suggested that although some networks may emphasize research, more are likely to be concerned with accountability, advocacy (especially for inclusive economic growth) and operational issues, such as productivity. At the same time, a strong working relationship between advocacy and research will be critical to ensure evidence-informed strategy options and quality evaluation. The central hub could make sense of this diversity, for example, by tightening its strategic focus – possibly around the goals of WHO’s “Global Strategy on HRH: Workforce 2030,” the outcomes of the UN High-Level Commission on Health Employment and Economic Growth or broad themes such as the Sustainable Development Goals (SDGs), or to support regional initiatives. One key informant suggested, “Use the network as a ‘collective brain’ to pool expertise, i.e. to identify where the next opportunities will emerge.”
Following from a clearly defined purpose, focusing on “the right network for the right issues” will be critical to avoid duplicating efforts of other groups. There are already many autonomous networks addressing HRH issues including vertical, disease-based programs that advocate for narrow HRH interventions in their areas of interest. It seems likely that even more autonomous groups will emerge, some less concerned with development issues and more focused on economic growth and labor market issues (Holmes et al., 2017; World Health Organization, 2016). Identifying the right stakeholders for the central hub’s governance role will require analyzing networks and actors both within and beyond WHO. Regional networks may play an important role, for instance to tackle HRH issues in high-income countries. It will be important to engage former GHWA members and others with a primary role outside the health sector, recognizing for instance, the increasing role of the private sector in delivering health services and pre-service education. It may also be strategic to look beyond health care and establish partnerships with organizations espousing related, but distinct goals, such as food security or education. Lessons learned and best practices can and should be gathered and shared widely to avoid duplication of effort, and to leverage resources and systems where possible.
Support the shared measurement of progress on agreed goals
Strengthening accountability systems has special relevance for HRH governance as noted earlier. Our literature review and key informants indicated that data collection capacities, progress indicators, and repositories pose significant issues for HRH governance (Connell et al., 2007; Holmes et al., 2017; Kaplan et al., 2013; Mikkelsen-Lopez et al., 2011; Pittman, 2015; Warren et al., 2013). Given the complex interplay of factors influencing HRH issues, it will be critical to align accountability processes with shared learning mechanisms for instance around common language and metrics. Developing system assessment and learning tools that employ continuous feedback from end-users will support global priority setting, advocacy by civil society groups at the national level and evidence to assess innovations. Fostering global monitoring and mutual accountability is a natural development, consistent with GHWA’s achievements at the global fora. Support for developing shared measurement and learning systems will also be helpful if the central hub chooses to prioritize assistance to countries in meeting SDG and Universal Health Care goals. Any success with accountability measures will depend on the central hub earning authority and legitimacy from stakeholders to deliver this sensitive responsibility on their behalf.
In this paper, we applied Shiffman’s model to analyze the ten-year legacy of GHWA. As a uniquely complex case in a rapidly evolving global environment, GHWA had a number of successes, some partial successes, and some failures.
Theories that assume a complex system, such as Shiffman et al.’s (2016) framework enable us to analyze the political issues and special interests influencing GHWA. The theories allow us to do so at a more fine-grained level, teasing apart policy environment, issue framing, and actors as a mechanism for understanding what happened, identifying emerging themes, and drawing lessons that can be applied to other networks, in other contexts. Because all three elements are examined closely, we can apply these lessons appropriately, in a nuanced and tailored way, and not as a blunt instrument expecting that one size fits all.
These dynamic and evolving influences are key aspects of context. Individual case narratives from key informants illustrated particular examples of political issues that either helped or hindered particular GHWA initiatives. Policy environments were either more or less conducive to efforts to manage these issues.
Adding the third “e” of evolution to the Shiffman et al. focus on emergence and effectiveness offers rich lessons in how complex networks adapt over time. Key learnings underscore the utility of a complexity perspective and the need to balance sometimes conflicting priorities with flexible structures and processes. Evolving complexity requires both ever greater focus on clear goals and innovation and ongoing renewal. Paradoxically, the apparent need for more stable structures must give way to greater reliance on shared learning around a flexible strategy tailored to local context. Challenges change as the network evolves, highlighting the need for continuous investment in relationships, trust, and capacity building. Key success factors for the backbone organization that implements the evolving strategy will be tight strategic focus, distributed leadership, adept orchestration of network members, and a responsive platform for shared measurement and learning.
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The Global Health Workforce Alliance (GHWA) funded the original study on which this paper is based. The GHWA Secretariat reviewed and approved the study design proposed by the research team; suggested a long list of the key informants from amongst its stakeholders; and commented on the penultimate draft of the report. Professor Greenhalgh is partly funded by a grant to the Oxford Biomedical Research Centre, NIHR BRC-1215-20008. The authors want to thank other members of the study team for their excellent contributions – Kevin Noel, Jennifer Bitz, Alexandra Wright, and Carol Herbert. The GHWA secretariat was not involved in final selection of key informants; nor in collection, analysis or interpretation of data; nor in approving or writing the final version of the study report; nor in contributing to or approving this paper; and nor in deciding to submit the paper for publication.
About the authors
Allan Best, PhD, is the Managing Director at InSource Research Group. He is also an Associate Scientist in the Vancouver Coastal Health Research Institute’s Center for Clinical Epidemiology and Evaluation, and a Clinical Professor Emeritus, School of Population and Public Health, University of British Columbia.
Alex Berland, MSc, is a Senior Associate at the InSource Research Group, Adjunct Faculty at the UBC School of Population and Public Health, and a Senior Adviser Health Sciences at the IUBAT – International University of Business Agriculture and Technology in Bangladesh.
Trisha Greenhalgh, MD, MRCGP, OBE, is a Professor of Primary Care Health Sciences at the University of Oxford, UK. She is a Senior Associate at the InSource Research Group and a Member of the Scientific and Technical Advisory Committee to the WHO Alliance for Health Policy and Systems Research.
Ivy L. Bourgeault, PhD, is a Professor in the Telfer School of Management at the University of Ottawa and the Canadian Institutes of Health Research Chair in Gender, Work and Health Human Resources.
Jessie E. Saul, PhD, is an Associate in the InSource Research Group. She is also the President and the CEO of North American Research and Analysis, Inc.
Brittany Barker, MPP, PhD Candidate, is an Associate in the InSource Research Group, and a Research Associate and a Project Coordinator for the British Columbia Centre on Substance Use/B.C. Centre for Excellence in HIV/AIDS.