Re-framing how we think about decision-making

3 lessons from healthcare workers and managers in Kenya

This is the second story in a series sharing initial insights from the Vaccine Delivery Data Research Study in Kenya. You can read the first story here. A full report of the initial findings is also available for download.

Cramped in a tiny office in a health facility in Western Kenya, our research team was sitting across from an immunization nurse named Susan*. We were feeling stuck. Susan was staring at us blankly while we shifted in our chairs.

We were there as part of a joint effort between Sonder Collective, John Snow Inc. (JSI), and the Ministry of Health in Kenya, to understand challenges around collecting and using data for decision-making in delivering immunization services. The approach we used, called Human-Centered Design, is a set of tools and methods that focus on understanding the unique needs of the individual actors of the system and help uncover behaviors, motivations, and attitudes that may be missed using more traditional research methods.

We were talking to Susan to hear about the decisions she was making as part of her daily work. In a mix of English and Swahilli, we had each taken turns asking the question, and probing with examples. As the nurse responsible for running immunization services, monitoring vaccine stock, and planning outreach activities, we knew she was making many decisions, some of which had a big impact on the overall immunization program.

Decision-making modes: Rather than describing decisions they make, most participants tended to describe their work in terms of routine tasks, planning activities, and instances of problem solving. Each one can be thought of as a different decision-making mode with unique data needs and processes.

But her message to us was clear: “Decisions are made at the top. We don’t make them here. We’re just given protocols to follow.”

While Susan’s perspective was extreme, it was consistent with our growing body of evidence, challenging widely held assumptions around decision-making in the health system, and helping us re-frame it in three important ways.

Not everyone thinks of themselves as a decision-maker (even if they make decisions frequently)

As our interaction with Susan illustrated, many individuals regularly making decisions about the immunization program, especially at the facility and Sub County level, don’t consider themselves to be decision-makers.

We found that nurses and administrators with a nursing background were more likely to see their role as following a set protocol where decisions are thought to be made by those higher up in the hierarchy. In this context, making individual decisions can be seen as going against protocol, which in most cases is highly discouraged and can give it a negative connotation.

Rather than describing decisions they made, most participants tended to describe their work in terms of routine tasks, planning activities, and instances of problem solving. Each one can be thought of as a different decision-making mode with unique data needs and processes.

Decisions are made by the collective, not by individuals

When decisions did occur, most participants, even those at higher levels of the system, considered them to be the result of a collective rather than individual process.

Types of decisions: We heard about different types of decisions from our participants: including technical, strategic, political, operational, and implementational. Implementational decisions are frequently thought of as tasks, not decisions, and are especially common at the facility level.

Working groups and committees bring together various perspectives, and are thought to produce more strategic decisions. “You get diverse knowledge from different players on how to tackle an issue. It drives your work and makes it faster,” said Mary, a County M&E Manager.

Collective decisions also provide collective responsibility, shielding individuals from facing any negative consequences should things go wrong.

Information is usually accessed in meetings and informal conversations, not the official systems

We found that managers at all levels of the system tended to spend the majority of their time in meetings, which had a significant impact on how data that inform decision-making is accessed.

These managers tended to consume data primarily through informal conversations with their staff or colleagues, during meetings or through formal data presentations. More often than not, they did not have the time or comfort level to access the data directly from the information management system.

Understanding perceptions and mental models around decision-making can help us more effectively support a strong data culture. For instance, modified supervision approaches and updated protocols can help move away from success being characterized as the perfect execution of protocol and towards taking the initiative that achieves the right outcome.

Understanding the context in which decisions are made is important for thinking about the channels and formats in which data can be accessed and incorporated into the process. For instance, many of the working groups our participants described relied on a single individual, most frequently the Records Officer, to provide relevant data for the meeting. Designing interventions specific to those individuals can have exponential returns on how data is used throughout the system.

From more insights from this study, stay tuned for additional stories in this blog series. You can also download our initial Kenya findings report for more information.

This story was co-written by Sarah Hassanen, Emilia Klimiuk, Wendy Prosser, and Chloé Roubert.

Read the next story in this series: Using Human-Centered Design to understand how data is used in delivering immunization services in Sub-Saharan Africa

The Vaccine Data Discovery Research study is a joint research effort between Sonder Collective and John Snow Inc. (JSI) to apply the Human-Centered Design approach in order to uncover and prioritize data specific pain points and challenges that healthcare workers and managers at all levels within a country encounter in delivering immunization services in Kenya, the Democratic Republic of the Congo, and Mozambique.

Sonder Collective specializes in the application of Human-Centered Design to social and health challenges, particularly in low resource settings. The Sonder team has intensive experience conducting design research in maternal and newborn child health, sexual and reproductive health and rights, community health, health supply chains and HIV in Sub-Saharan Africa. John Snow Inc. (JSI) is a public health management consulting and research organization that works to improve health outcomes through strengthening health systems in partnership with country Governments. JSI works across immunization, maternal newborn and child health, nutrition, supply chain system design, paper based and digital information systems globally. JSI has led on immunization on USAID flagship projects like the Maternal and Child Survival Program, TSHIP and has been a key partner on MEASURE Evaluation for the past 20 years.