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Abstract
Introduction An organisation’s ability to learn and adapt is key to its long-term performance and success. Although calls to improve learning within and across health organisations and systems have increased in recent years, global health is lagging behind other sectors in attention to learning, and applications of conceptual models for organisational learning to this field are needed.
Leveraging the 4I Framework This article proposes modifications to the 4I framework for organisational learning (which outlines the processes of intuition, interpretation, integration and institutionalisation) to guide the creation, retention and exchange of knowledge within and across global health organisations.
Proposed Expansions Two expansions are added to the framework to account for interorganisational learning in the highly interconnected field: (1) learning pathways across organisations via formal or informal partnerships and communities of practice and (2) learning pathways to and from macro-level ‘coordinating bodies’ (eg, WHO). Two additional processes are proposed by which interorganisational learning occurs: interaction across partnerships and communities of practice, and incorporation linking global health organisations to coordinating bodies. Organisational politics across partnerships, communities of practice and coordinating bodies play an important role in determining why some insights are institutionalised while others are not; as such, the roles of the episodic influence and systemic domination forms of power are considered in the proposed additional organisational learning processes.
Discussion When lessons are not shared across partnerships, communities of practice or the research community more broadly, funding may continue to support global health studies and programmes that have already been proven ineffective, squandering research and healthcare resources that could have been invested elsewhere. The ‘6I’ framework provides a basis for assessing and implementing organisational learning approaches in global health programming, and in health systems more broadly.
- organisation of health services
- organisational development
- decision making
- international health services
- information storage and retrieval
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- organisation of health services
- organisational development
- decision making
- international health services
- information storage and retrieval
Introduction
An organisation’s ability to learn and adapt is key to its long-term performance and success.1 Organisational learning encompasses the processes of creating, retaining and exchanging knowledge, and is broadly understood as ‘a change in the organisation that occurs as the organisation acquires experience’.1 Organisational learning occurs over time and is highly dependent on both internal context (ie, within the organisation) and external context (ie, the environment within which the organisation operates).2
Global health is lagging behind other sectors in attention to learning.3 4 Although definitions have been contentious, global health has been defined as ‘collaborative transnational research and action’ for promoting health and health equity for people worldwide.5 The global health sector currently employs a narrow definition of learning, often tacitly assuming knowledge generation as inherent to global health operations or reducing learning to rapid clinical data generation.4 The Director-General of WHO, Dr Tedros Ghebreyesus, states that active investment in, and attention to, learning is critical for achieving universal high-quality healthcare globally6:
All of this requires attention to developing active learning systems… We must go deep into the messy realities of health services to understand local problems, find innovative solutions, learn from mistakes, scale up what works, and share experiences. Local learning needs to be prioritised, but local lessons must also be shared nationally and with the world.
Global health organisations operate in a rapidly changing environment that is influenced by the effects of globalisation, multipolarity and increasingly complex health challenges.7 The global health sector is undeniably political,8 and there are growing calls to address the existing power imbalances between high-income country (HIC) and low-income and middle-income country (LMIC) partners in the movement to decolonise global health research and practice.9 Organisational learning from individual to institution and back will be critical for navigating these transformative shifts, but few conceptual models that account for interorganisational learning exist in the field.
Although the basic logic of the 4I (intuition, interpretation, integration and institutionalisation) framework, a seminal piece in the organisational learning literature, appears to be relevant to the kinds of learning challenges facing global health, the framework does not account for key features of the global health enterprise, specifically interorganisational learning through communities of practice, formal and informal partnerships and coordinating bodies. The global health sector is highly interconnected by nature.10 Multiple organisations typically work together on a single programme or towards a shared goal, often set by a coordinating body (eg, WHO). This paper proposes two expansions (partnering organisations and coordinating bodies) to the 4I framework, and two additional ‘Is’—interaction and incorporation—to outline a model that addresses interorganisational learning and responds to the complexities of global health organisations, that is, a model that is multilevel, dynamic, clarifies process and considers the role of power differentials.
Leveraging the 4I framework of organisational learning
Individual learning at any level of the organisation is clearly important for the organisational learning process, but alone is insufficient. The learning from an individual must be ‘embedded in a supra-individual repository so that others can access it’,1 and the necessary processes for this multilevel organisational learning are outlined in the 4I framework developed by Crossan et al.11 The framework proposes that organisational learning occurs at three levels—individual, group and organisation—and that it consists of feed-forward learning processes that relate to exploration of new ideas from the individual to organisation, and feedback learning processes that relate to exploitation of those ideas from organisation back to the individual through embedded rules, procedures, routines and systems.
The first ‘I’—intuition—occurs at the individual level and refers to the initiation of a preconscious idea or novel insight which is generated through experience or the recognition of a pattern. The next step in organisational learning is interpretation, which is the process of the individual translating the idea from the preconscious to conscious level, either through language or action, to one’s self and to others.11 At this stage, the idea is made explicit, and may then be ‘incorporated into cognitive maps that relate the new idea to other ideas and to external domains’.12 Many ideas may stagnate at this step, as individuals may be unable or unwilling to translate them into interpretations that can be shared and accepted by others.12 The third process is integration, which occurs at the group level and is the process by which the interpreted idea arrives at a shared understanding between many individuals and becomes the basis for communal and coordinated action.11 Finally, the fourth process is institutionalisation, in which the shared action is embedded into the fabric of the organisation through rules, procedures and routines. Intuition, interpretation and integration serve as the ‘feed forward’ mechanisms for organisational learning, while institutionalisation occurs at the organisation level through ‘feedback’ to the group and individual levels.11
Of course, not every idea becomes institutionalised, and there are a range of barriers and facilitators at each step of the organisational learning process that can impede or advance ideas to the next level.13 Interested actors play a critical role in the advancement of new ideas towards institutionalisation.14 Although Crossan et al cite many contingencies surrounding their proposed four-step process of organisational learning, including people and the environment, the original 4I framework does not address the politics that necessarily exist within organisations as they navigate negotiation and conflict, or how different forms of power may privilege certain ideas over others. Lawrence et al added this political dimension to the framework in 2005, drawing from theories that define power in two broad buckets: episodic and systemic power. In short, the Crossan et al model demonstrates how organisational learning occurs from individual to organisation, and the Lawrence et al additions outline why some insights may be given priority over others. The 4I framework with modifications incorporating power and politics is depicted in figure 1.
Episodic power typically takes the form of influence or force exerted by an individual at some specific stage of a process. Actors can assert power through influence by shaping the costs and benefits of certain behaviours, for example, through negotiation or ingratiation. Influence is most relevant at the interpretation process of organisational learning, when an actor who has ‘control of scarce resources, domain-relevant expertise and culturally appropriate social skills’ can champion an idea to become accepted by others.12 Actors can also affect organisational learning through force, by purposely manipulating options in order to direct the course of outcomes, for example, through restricting or directing agenda items, or by limiting the introduction of alternative solutions. Force is typically carried out by actors with formal authority, and is most influential at the integration stage to move ideas from the group to organisation level.
Systemic power, on the other hand, operates through ‘the routine, ongoing practices of organisation’ and takes the form of domination or discipline.12 Domination is most influential in the institutionalisation process of organisational learning, in part because change to existing practices is often resisted15 and must be overcome through the restriction of available behaviours. Examples of domination include altering information systems to provide only certain response options, or in the case of factories, altering the physical layout of a space to encourage uptake of the new behaviour. Perhaps more surprisingly, systemic power is also most influential in determining whether ideas do or do not progress from the individual to organisation via the fourth ‘I’ of organisational learning (intuition) in the form of discipline. Individuals call on personal expertise and identity in order to recognise their subconscious ideations as potentially solving a problem, and discipline works systemically (or not) to enhance those abilities, for example through training, socialisation, or team-based work.12
A proposed expanded framework for interorganisational learning in global health
The 4I framework provides a strong model for organisational learning in global health because, first, it accounts for the multilevel nature of global health organisations and learning processes, addressing the individual, group and organisational levels for analysis. Second, it articulates the four specific learning processes—intuiting, interpreting, integrating and institutionalising—which together make up the essential steps in organisational learning. Third, the framework addresses both learning that ‘feeds forward’ to the organisational level as well as learning that ‘feeds back’ to the individual level. Finally, the modified version incorporates aspects of politics and power associated with each learning process, a critical consideration as global health organisations and programmes are political by nature, operate in a political context and have heightened power differentials between individual and organisation levels.
However, the 4I framework fails to address organisational learning that is inherent to global health programming on two significant levels: (1) learning that occurs through partners and communities of practice and (2) learning through coordinating bodies. In the following sections, we introduce the two expansions and eight underlying rationales (summarised in table 1) to the 4I framework to account for interorganisational learning across both partnerships and communities of practice and coordinating bodies to be more responsive to global health learning challenges.
Overview of the two proposed framework expansions, and eight underlying rationales, to the original 4I framework to increase responsiveness to global health organisational learning challenges
Expansion 1: interorganisational learning through partnerships and communities of practice
Rationale 1. Global health organisations learn from one another via communities of practice, and through formal and informal partnerships.
The relationship between the individual, team and organisational levels of learning is still poorly understood,16 and the sociopolitical context for organisations that operate globally adds to the existing complexity of learning within an organisation.17 In addition to intraorganisational complexities, global health organisations are highly interconnected10 and have to rely on extensive collaboration to pursue their individual missions, working together through formal and informal partnerships and forming communities of practice. Such formal and informal networks have been noted to enable learning by creating opportunities to share ideas.16
Organisations in global health may come together in formal or informal partnerships over shared concerns for specific health needs (eg, malaria, vaccines, smoking cessation), geographic-specific health needs (eg, low-income countries, global regions), specific population needs (eg, people living with HIV) or in working towards a specific health-related goal (eg, achieving universal health coverage, addressing climate change).18 Formal partners may be bound through contractual or financial agreements, while informal partnerships and extra-organisational communities of practice in global health differ in their ‘relatively diffuse systems of authority’ and voluntary membership.18
Communities of practice play a critical role in connecting working, learning and innovation.19 Addressing and directing learning in the workplace through conventional approaches like manuals, job descriptions, training programmes and standard operating procedures does not capture the complexity and reality of organisational learning.19 A community of practice can be defined as a group of people with common interests who purposefully interact to share expertise and knowledge around problems and existing practices to advance collective learning. Interorganisational learning through partnerships and communities of practice is essential to achieving wide-reaching goals like those outlined by global health organisations, and as such must be accounted for in an expanded 4I framework for application to global health programming.
Rationale 2. New and established ideas are shared across communities of practice or between formal and informal partnerships by way of a ‘5th I’ process of organisational learning—interaction.
Beyond intuition, which is firmly an individual-level process, the other learning processes of interpretation, integration and institutionalisation may be less strictly constrained to one ‘level’.11 Crossan et al state that ‘interpreting is a social activity that creates and refines common language, clarifies images and creates shared meaning and understanding’. Ideas do not have to necessarily have reached the full ‘integrated’ stage at the organisation level in order to be shared through a community of practice or partnerships, as these social spaces can themselves be generative.
Certain network characteristics have been highlighted as enabling interorganisational learning, including ‘relational strength (the frequency of communication, the duration of contact over time, intimacy or degree of agreement), legitimacy (a person’s position, eg, status, authority) and trust’.16 Shared understanding is required among a group for coherent, collective and integrated action to be achieved, and this can only be accomplished through shared experiences and ongoing conversation among community members.19 The key mechanism for interorganisational learning therefore lies in the interaction that occurs when individuals from different organisations are given the space to share, discuss, think, learn and unlearn.
Rationale 3. The sharing of new and established ideas across communities of practice or between formal and informal partnerships will be best facilitated by the episodic influence form of power.
Partner networks (including communities of practice) are one of the most influential mechanisms for organisational learning in a global organisation, and each actor brings a different degree of ‘connectivity and power’ to influence learning flows.17 A deep-rooted history of colonialism imparts a profound backdrop of power dynamics across global health organisations and partners.9 Compounding these power dynamics is the fact that individuals working at the interface of global health programmes, such as remote community health workers, have extremely disproportionate power compared with those at the organisational level, so intraorganisational learning may be restricted or impacted in global health programmes, particularly at the intuition and interpretation levels.
In an assessment of power, status and learning in organisations, Bunderson and Reagans report that ‘higher-ranking actors who use their power and status in more “socialised” ways can play critical roles in stimulating collective learning behaviour’.20 As such, episodic power, or the form that is enacted by individuals rather than systems, is most likely to be effective in shaping organisational learning through the interaction process across partnering organisations. And, because global health organisations operate through a polycentric governance system, episodic influence, or the act of ‘interpreting an idea so that it becomes accepted by others’ through means such as ‘moral suasion, negotiation or ingratiation,’12 is likely to be more effective than episodic force at this level. In order to use episodic influence effectively, an actor must have control of, or access to, scarce resources, relevant expertise and culturally appropriate social skills.12
Expansion 2: interorganisational learning through coordinating bodies
Rationale 4. Global coordinating bodies add an additional macro-level to the 4I framework that is necessary for consideration of organisational learning in global health programming.
Leaders influence an organisation’s readiness and ability to learn and adapt by instituting structures and ‘knowledge networks’ that can act as learning catalysts, and these can be effective both within and across social networks.21 Global health leaders likewise need a coordinated approach to institute programmatic learning across partnering organisations, and to espouse a culture of learning.4 For a polycentric governance system (ie, having multiple centres of power that remain formally independent) like those of global health programmes to function, there must be shared goals, understandings and norms.7 Shared goals, for example, the United Nations’ Sustainable Development Goals (SDGs), are often set, advocated for and tracked by one or more coordinating bodies (eg, WHO, the United Nations Development Programme).22 Organisational learning is a process of developing shared understandings and beliefs that are then institutionalised, and in global health programmes, a coordinating body can hasten or impede this progress by setting shared goals, promoting certain approaches and directly funding or advocating to fund certain priority activities.8
The addition of a fourth level to the macro end of the 4I framework adds an additional layer of social and political complexity that is necessary to account for the global structures which direct and influence the actions of global health organisations. Much of the literature focuses on the negative implications of power for creativity, but Carlsen et al explored some of the positive aspects of power and its potential for amplifying creativity in organisations. The role of coordinating bodies in institutionalising practices can be a positive force when engaging in learning from a ‘power with’ or ‘power to’ lens, rather than from a position of having ‘power over’, which enables exploration and creativity.23
Rationale 5a. New ideas are fed forward from the organisation level to the coordinating body via a ‘6th I’—incorporation.
Rationale 5b. Established ideas are fed back from the coordinating body to the organisation(s), group and individual levels via institutionalisation.
An increasingly globalised world has brought with it an influx of new financing, transnational initiatives, organisations, alliances and consortia into the global health sphere, a welcome growth but bringing with it a pluralism that has led institutions to divide in order to address the changing agenda.24 The result is a less coordinated, ad hoc approach that carries implications for organisational learning in global health. New ideas are fed forward to a coordinating body like WHO from the multitude of sources at the organisational level, spanning individual organisations, formal and informal partners and communities of practice. Global health governance is a complex adaptive system, in which networks are fluid and inter-related, and actors’ roles can transform and realign.24 Balancing the tensions between autonomy and interaction of global health organisations adds to existing challenges for coordinating bodies to manage paradoxical tensions (eg, between exploration and exploitation).25 Coordinating bodies must make sense of this rush of information through a ‘6th I’—incorporation.
Established ideas at the coordinating body level are fed back to the organisation, group and individual levels by institutionalisation through directives, manuals, strategies and routine practices. Institutionalisation of ideas allows individual and communal learning to be accessed by others, and in order for an idea to become institutionalised, it will typically have garnered support, consensus and shared understanding behind it; institutionalised ideas tend to endure for a long time,11 for better or for worse.
Rationale 6a. The sharing of new ideas from organisations to coordinating bodies will be best facilitated by the episodic influence form of power.
Rationale 6b. The institutionalisation of ideas by a global coordinating body will be best facilitated via the systemic domination form of power.
A systematic review of the mechanisms that facilitate learning flows identified many mechanisms contributing to feed forward learning but only three mechanisms—‘leaders, shared mental models and organisational initiatives’—that consistently contribute to feedback, or institutionalised, learning.16 This suggests that both episodic and systemic power will be at play in enabling organisational learning though coordinating bodies. Individual leaders use political influence, through tactics like negotiating over the costs and benefits of new behaviours, to move ideas onto agendas and budget lines of coordinating bodies. Individuals that hold power within an organisation can positively or negatively influence learning through political interventions.17
On the other side, the systemic domination form of power will be most effective in institutionalising learning from coordinating bodies down the feedback chain in order to proactively address potential resistance to change, for example, by restricting options available to other members of the organisation. It is important to note that ‘not all such systems and structures are equally effective in achieving the institutionalisation of an innovation’,12 so even once an innovation is institutionalised by coordinating bodies, it may be taken up and put into practice at very different rates across the sector.
The resultant ‘6I’ framework incorporating the propositions to account for interorganisational learning in the global health sector is depicted in figure 2.
The ‘6I’ framework of organisational learning that builds on the original and expanded 4I models by Crossan et al 11 and Lawrence et al 12 by adding the processes of interaction and incorporation, and the interorganisational levels of coordinating bodies and partnership/community of practice components.
Discussion
Creating an enabling environment for organisational learning is a strategic design decision. Enabling conditions for a learning health system have been described as a combination of leadership and culture, system design and necessary financial and human resources.4 The expanded ‘6I’ framework accounting for interorganisational learning may guide the design and evaluation of such enabling environments in global health organisations, and is likely applicable to other health settings and global sectors, or to any sector which is highly collaborative and interconnected across organisations. Some reports have suggested that global health governance is already well-situated for organisational learning.7 In these cases, the framework can guide future studies in exploring the proposed mechanisms through which organisational learning operates, identify opportunities to improve effectiveness, critically examine the political nature of organisational learning processes and consider how organisational learning may be sustained.
The global health sector is currently pushing for universal health coverage and substantial shifts in approach to address the ambitious health priorities set forth in the SDGs.22 Organisational learning is critical for these transitions and for restoring power back into the hands of countries.26 Power plays an important and underexplored role in how agenda-setting occurs even at these highest levels—for example, although the United Nations’ SDGs were informed by extensive consultations with governments and other actors, the goal-setting process may have been influenced by the structural and productive power that privileged certain issues over others.27 Furthermore, the distribution of leadership roles in the global health sector is itself inequitable. A staggering 84% of leadership positions in global health are held by individuals in HIC, and men continue to hold 70% of all leadership positions.28 This representation has direct implications for power, politics and interorganisational learning. The framework presented here could be used to assess which processes along the organisational learning pathway in global health programmes are strongest and weakest, where power imbalances are particularly influential, and to identify enabling factors and barriers to improve learning in global health.
Organisational learning extends beyond the mere collection and distribution of data points or the enhancement of evidence-based learning in a clinical setting, although these undeniably constitute critical aspects of a robust public health system. Organisational learning is also about stakeholder experiences in the day-to-day delivery of global health programmes, and translating individual know-how into ‘change in the organisation that occurs as the organisation acquires experience’.1 It is about the process of arriving at a shared meaning11 29:
The distinctive feature… is sharing. A piece of data, a perception, a cognitive map is shared among managers… Passing a startling observation among members, or discussing a puzzling development enables managers to converge on an approximate interpretation.
Failing to address innovative ideas and approaches can have detrimental effects; when ideas from the individual and group levels are not institutionalised or implemented at the organisational level, individuals and groups stop generating new ideas.30 Framing organisational learning through the 6I framework can expand the understanding of, and actions behind, ‘learning health systems’ in global health.
Finally, the incredibly rich literature from the organisational management field could help sort through some of global health’s ‘wicked problems’. The management literature features decades of theoretical and empirical research on organisational learning. Organisational management theories and frameworks have been drawn on widely by the sociology, economics, information systems, engineering and strategic management fields.1 This is a call for the global and public health sectors to tap into this wealth of research and resources.
Conclusion
Lawrence et al proposed an explicit focus on the power and politics behind the processes of organisational learning outlined in the 4I framework to explain why some ideas and insights are institutionalised, while others are not. Prioritising only the insights which have been advanced by powerful actors and systems has strong moral implications relating to budget development, resource allocation, research agenda setting and beyond. Additionally, when lessons are not shared across partnerships, communities of practice or the research community more broadly, funding may continue to support global health studies and programmes that have already been proven ineffective,26 squandering research and healthcare resources that could have been invested elsewhere.
Approaches that are inclusive of both intraorganisational and interorganisational learning may open the pathway for creative solutions, equitable decision-making and genuine change in global health. A conceptual model for organisational learning in the complex, interconnected and political global health sector is needed to achieve the ambitious and pressing new directions of the field. Learning through numbers is not enough. Organisational learning can give voice to stakeholders across the sector, and the expanded ‘6I’ framework provides a model to create, refine and assess programmatic abilities to achieve their goals.
Ethics approval
Not applicable.
Footnotes
X @BreannaWodnik, @ed4socialchange, @LaveryJim
Contributors All authors contributed to the conceptualisation of this work. BKW conducted the literature review and drafted and revised the paper; MA, EDR and JL revised the paper.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.