RESUMEN
Background: Processes of self-reflection and the learning they allow are crucial before, during, and after acute emergencies, including infectious disease outbreaks. Tools-such as Action Reviews-offer World Health Organization (WHO) member states a platform to enhance learning. We sought to better understand the value of these tools and how they may be further refined and better used. Methods: We searched the publicly available WHO Strategic Partnership for Health Security website for paired reports of Action Reviews, that is, reports with a comparable follow-up report. We complemented the paired action reviews, with a literature search, including the gray literature. The paired action reviews were analyzed using the "Learning Health Systems" framework. Results: We identified three paired action reviews: Lassa Fever After Action Reviews (AARs) in Nigeria (2017 and 2018), COVID-19 Intra-Action Reviews (IARs) in Botswana (2020 and 2021), and COVID-19 IARs in South Sudan (2020 and 2021). Action Reviews allowed for surfacing relevant knowledge and, by engaging the right (in different contexts) actors, asking "are we doing things right?" (single loop learning) was evident in all the reports. Single loop learning is often embedded within examples of double loop learning ("are we doing the right things?"), providing a more transformative basis for policy change. Triple loop learning ("are we learning right"?) was evident in AARs, and less in IARs. The range of participants involved, the level of concentrated focus on specific issues, the duration available for follow through, and the pressures on the health system to respond influenced the type (i.e., loop) and the effectiveness of learning. Conclusion: Action Reviews, by design, surface knowledge. With favorable contextual conditions, this knowledge can then be applied and lead to corrective and innovative actions to improve health system performance, and in exceptional cases, continuous learning.
RESUMEN
A health system has three key stakeholders, the State-at national and subnational levels-the health service providers and the citizens. In most settings and especially in peacetime, these stakeholders are typically well-defined. In contrast, during conflict and crisis as well as during ceasefire and post-conflict peacebuilding, stakeholders in the health system are often more diverse and contested. Health systems in such settings tend to be more decentralised, de facto-often in addition to de jure decentralisation. Despite much debate on the potential benefits of decentralisation, assessing its impact on health system performance remains difficult and its effect is open to dispute in the literature. This narrative synthesis aims to support efforts to assess and make sense of how decentralisation impacts health system performance in fragile and post-conflict countries-by synthesising evidence on the impact of decentralisation on health system performance from six country case studies: Papua New Guinea, the Philippines, Indonesia, Pakistan, Myanmar and Nepal. The impact of decentralisation on health system performance is optimised when combining centralisation (e.g., the benefits of central coordination in improving efficiency) with decentralisation (e.g., the benefits of local decision making in improving equity and resilience). The findings may inform efforts to think through what to centralise or decentralise, the impacts of those choices, and how the impact may change over time as countries go through and emerge from conflict-and as they go through and recover from the Covid-19 pandemic and prepare for future pandemics.