How do you work with governments to integrate innovations into health systems?

The Resilient Health Systems (RHS) theme of COVIDaction consists of awardees that harness the power of technology to improve health data and service delivery. The commonalities between awardees’ objectives and challenges allowed the COVIDaction team to put together a shared learning agenda that could be used to enhance coaching support across RHS. Following our first blog in the RHS learning series, we now share what we found from exploring the second question in the RHS learning agenda: what are the success factors for integrating an innovation into the broader health system at scale?

The mission of COVIDaction’s Resilient Health System (RHS) theme is to explore the role of technology in building the capacity of health systems to withstand, adapt, and transform from shocks to the system. One of the unique aspects of working in healthcare relative to other fields is the degree of dependency between innovators and government in achieving meaningful changes to health systems. In many of the countries where RHS awardees work, people rely on a mixed health system comprising of a network of for-profit, not-for-profit, and public sector inputs. There has been increasing efforts to ensure that all of the key players in a mixed health system align with government health priorities. Additionally, healthcare is often highly regulated, and navigating the landscape of policies and regulations that may impact the use and scalability of an innovation is daunting.

For an innovation to truly make an impact on health system resilience, it must be adopted by the health system for system-wide use — that is, the innovation needs to be integrated into the broader health system at scale. We wanted to help awardees plan for the integration process, including how to engage government stakeholders, assess potential barriers and entry points for integration, and design towards the end goal of full integration into the health system. So we asked the following question, what are the success factors for integrating an innovation into the broader health system at scale?

Integration into the broader health system has been approached and has played out in different ways across the different awardees on the RHS portfolio. For example, in Isingiro District in Uganda, Medical Teams International and Shifo Foundation are piloting an innovative yet simple solution called Smart Paper Technology to scan and digitise individual health records. Collaboration with the Ugandan government is critical for their success so that they can integrate their data into the existing government platforms to maximise efficiency and impact. In Kenya, Wheels for Life hopes to integrate their tele-consultation, triage, and emergency transport service by embedding into public and private insurance packages, which will require sustained engagement with government and other health system actors.

Awardees are at different stages in terms of their implementation and scale up, so the recommendations on integration into the broader health system might serve different innovators in different ways. For the early stage innovators, these best practices help outline a roadmap or checklist of things to consider and accomplish. For more advanced innovators, it might help with a retrospective review activity, to help assess which key components they successfully accomplished, and where they might want to revisit.

From scoping the literature, we identified five cross-cutting success factors for public sector innovation integration.

These five success factors for integrating an innovation into the broader health system can be put into practice by innovators to increase the odds of successful integration.

1. Engage early — For government engagement, the earlier the better. By engaging early, innovators can identify public sector ‘champions’, who can advocate internally for the innovation, and forecast challenges, such as financial constraints.
2. Assess the policy landscape — Existing policies and regulations will govern the use of the innovation. Innovators should assess whether innovation fits within the existing landscape, or whether they will need to adapt their innovation to ensure its integration.
3. Be clear on the why — Innovations naturally evolve as they go from concept to prototype to fully-scaled component of a system. But not all of that evolution is within the innovator’s control. To ensure the innovation still fulfills its initial purpose, the innovator should put the why, the central issue that the innovation addresses, front and center in every conversation with government stakeholders. This should help preserve the integrity of the innovation’s mission through the integration journey .
4. Prepare to manage disruptions — Integrating any innovation will cause disruptions; the goal is to minimise or manage them. The smaller the ‘ask’, the more likely the innovation will be integrated. Innovators should consider who might lose politically or economically if the innovation is fully adopted, as well as who is benefiting most from the status quo. These individuals are likely to be the most disruptive to integration, and should be intentionally engaged on the why.
5. Collaborate on multiple levels — From local leaders to national Ministries of Health, every level of government should be engaged. While national partners may be a more obvious target for integration, local governments should also be engaged. Often local governments have stronger relationships with local partners and can help secure buy-in and promote the technology’s usage.

We wanted to push further than just handing innovators a list of good ideas. We wanted concrete methods for operationalising them. Using these success factors, we generated a series of activities that coaches and innovators can use to take action.

• Reflection questions were selected to help innovators and coaches identify blind spots and opportunities for growth within each success factor.
• A stakeholder mapping exercise was modified to the needs of awardees. This activity helps visualise stakeholders’ interest and influence over integration, assisting innovators to engage on multiple levels and prepare to manage disruptions.
• Making sense of the web of policies and regulations that govern the use of an innovation and its scale up is daunting, so we created a policy landscaping matrix to structure an approach to doing so. This matrix has three dimensions with the aim of helping innovators accomplish three things:

1) Determine the policies and regulations that will affect their usage

2) Identify any barriers to the innovation’s core function or expanded use in the health system and generate a plan to address barriers

3) Consider the capacity building activities that will be necessary to train users to properly implement the innovation and/or to train decision-makers to harness the power of the data the innovation unlocks

We developed three matrices specific to health technology solutions to guide a policy analysis. The guide covers policy landscaping, tool development, and end user training.

• Interactive Miro facilitation guide to plan for a government engagement focusing on the why. High stakes meetings with the government are important to get right, and the best way to ensure those go well is to prepare.

This interactive Miro board was developed to assist awardees with planning a meeting with the government to discuss integration of a technology. The planning is broken down into four stages: pre-meeting preparation, meeting kick-off, activity planning for the bulk of the meeting’s agenda, and the conclusion and follow up from a meeting.

This Miro board has four panels corresponding to four distinct planning stages:

1. The first panel walks through various pre-meeting considerations, such as clarifying meeting objectives and participant lists.
2. The second panel walks agenda considerations for beginning the meeting, like how much to rely on pre-work versus an introductory presentation to equip those attending to fully participate.
3. The third panel provides different ideas for what to do for the bulk of the meeting based on the objectives
4. The fourth panel walks through considerations on how to conclude and follow up with participants after the meeting.

This interactive Miro board was developed to assist awardees with planning a meeting with the government to discuss integration of a technology. The planning is broken down into four stages: pre-meeting preparation, meeting kick-off, activity planning for the bulk of the meeting’s agenda, and the conclusion and follow up from a meeting.

Acknowledging that each innovation’s path to integration will be unique, we wrapped up our work by compiling a vault of practical resources including stakeholder mapping and engagement and policy landscaping.

Scaling any health solution in the long term depends on getting government buy-in, whether that applies to aligning an innovation to regulatory guidelines or modifying some aspect of the public sector health system. Additionally, the route to scale for most health innovations will be via integration with existing structures. This work can be challenging and time intensive, but the pay-off can be huge: a fully scaled innovation making sustainable contributions to health system resilience. This is the unified vision of the COVIDaction RHS awardee, and we hope these tools and findings help bring that vision closer to realisation.

To read more about findings from previous rapid learning cycles conducted by the team, check out these two blogs posts: Rapid Research Cycle One and Rapid Research Cycle 2.