Peer Learning Strengthens Health Systems

Consider Nepal. It’s made great progress on health outcomes. Neonatal mortality fell 58 percent from 1996 to 2016 while between 1996 and 2022, infant mortality declined 64 percent and under-5 mortality fell 72 percent. The percentage of women who gave birth and received some antenatal care from a skilled provider skyrocketed 376 percent from 1996 to 2022.

Yet gaps remained. Municipalities and health facilities vary widely in their ability to plan, manage, and deliver quality health services. The USAID-funded, Abt Global-led Strengthening Systems for Better Health (SSBH) helped address these differences. Working hand-in-hand with districts and municipalities, SSBH organized peer-learning and experience-sharing sessions at both the district and municipal levels for health section staff and health providers. These teams shared innovative approaches and solutions to common challenges they faced, from budgeting and procurement of essential medicines, to improving the clinical quality of services

For example, Birendranagar Municipality shared its experience with implementing a free sanitary pad distribution program. Representatives discussed the challenges they encountered over time and how they modified the program to address resource constraints. Similarly, Chaukune Municipality shared its experience with expanding health facilities, expressing concern about the average number of client visits, with some health facilities having only two to three client visits per day.

Meeting participants discussed these challenges and made commitments to adopt best practices from their peers in their own municipalities and agreed to report back on progress.

Rwanda has had similar success. It’s made remarkable gains in healthcare over the last two decades. Community-based health insurance now covers more than 83 percent of the population, up from 27 percent in 2004. That contributed to a 77 percent reduction in mortality rates for children younger than five and an 81 percent decline in maternal mortality from 2000 to 2020. But the progress masked significant differences in capacity and performance among districts and hospitals.

Rwanda’s Twinning Partnership Network (TPN) adapted the World Health Organization’s Twinning Partnerships for Improvement (TPI), which paired a high-performing health institution with a lower performing partner through a six-step improvement cycle. The TPI process has resulted in significant improvements in both COVID and Ebola responses in settings as diverse as Liberia, Tanzania, and Bangladesh.

The twinning network, which I supported while at RTI International, was the major innovation in Rwanda.  Rather than developing a twinned pair with two institutions, the twinning network facilitated one district or hospital to provide support to another in an area of strength and receive support in an area of weakness, creating a web of twinning relationships. The twinning network provided support across a range of potential issues, including community-based health insurance (CBHI) enrollment, accreditation scores, birth asphyxia, malnutrition, and increasing antenatal care visits. With

Using this method, accreditation scores improved by 5.6 points (of out 100 possible) more in TPN hospitals that selected accreditation than those that did not. Districts that wanted to increase CBHI uptake improved their coverage by 3.6% more than districts that did not focus on the topic. Senior management’s interest and motivation to improve in the areas they chose was one reason for the results. Context-specific knowledge sharing from peer hospitals and districts also played a role.

Supply chain issues are chronic problems the partnerships discussed. During one virtual session, a hospital staffer was on his phone, walking around the pharmacy at his hospital and showing others in the session how he was managing his pharmaceutical supply chain. People from the other hospitals who were in the session peppered him with questions and shared experiences around pharmaceutical management. It was an effective learning event for all in attendance.

Ethiopia has made progress as well. It achieved the maternal and child health targets set in the Millennium Development Goals, reducing maternal mortality by 75 percent and under-five mortality by 50 percent by 2016. But wide variances remained among district health offices in know-how, skills, competencies, and performance. So, eight districts embarked on year-long twinning partnerships, pairing high performing districts with low performing ones.

Improvements in health systems outcomes were statistically significant. The mean score for community-based health insurance rose from 15.0 to 19.74. The overall District Health System Performance score increased from 50.97 to 72.07. 

The peer-learning approach also produced qualitative results. One health center director noted that he had never talked to neighboring districts to share information about improving health services because he wanted his district to stand out. But the twinning partnership opened his eyes. “We understood that through working together, we became stronger,” the director said. “The partnership helped us get closer to our ultimate goal of serving the community.”