Gates Open Res Gates Open Research 2572-4754 F1000 Research Limited London, UK 10.12688/gatesopenres.14699.1 Research Article Articles Strengths and weaknesses of the South-South Learning Exchange: a qualitative analysis of experts’ perspectives

[version 1; peer review: 1 approved, 1 approved with reservations]

 Triulzi Isotta Conceptualization Data Curation Formal Analysis Investigation Methodology Validation Writing – Original Draft Preparation https://orcid.org/0000-0002-1421-7863 a 1 Kabra Rita Conceptualization Funding Acquisition Project Administration Supervision Validation Writing – Review & Editing https://orcid.org/0000-0001-6595-2035 2 Allagh Komal Preet Conceptualization Investigation Methodology Supervision Writing – Review & Editing 3 Kiarie James Conceptualization Funding Acquisition Methodology Project Administration Supervision Writing – Review & Editing https://orcid.org/0000-0003-4180-7858 2 Institute of Management, Scuola Superiore Sant'Anna, Pisa, 56127, Italy Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, 1211, Switzerland Consultant, Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, 1211, Switzerland isotta.triulzi@santannapisa.it

No competing interests were disclosed.

 18 8 2023 2023 7 116 27 6 2023 Copyright: © 2023 Triulzi I et al. 2023 This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background: 

South-South learning exchange (SSLE) refers to an interactive learning process where peers exchange knowledge and experience to work towards a beneficial change. Despite organizations having recently increased the opportunity to run SSLEs, the SSLE support mechanisms and processes are not well documented in the scientific literature. This study explored experts’ perspective on SSLEs, strengths, weaknesses and mechanisms leading to outcomes.

Methods: 

We conducted a qualitative study using semi-structured interviews on experience of participants and organizers of SSLEs. Data were collected between 1 st September 2021 to 26 th November 2021. All data were digitally recorded, transcribed verbatim, and analysed. In the analysis, we adopted an inductive approach derived from thematic analysis.

Results:

Sixteen experts who have participated in or facilitated one or more SSLE were interviewed. Experts’ accounts demonstrated an appreciation of participants’ empowerment, positive peer-to-peer “mind change” and convincing and powerful hands-on learning of this approach as strengths in the successful implementation of the SSLE. Being resource heavy, participant reluctance and absence of a validated methodology emerged as main weaknesses of the South-South learning approach, which could impair the effectiveness of this scheme.

Conclusions: 

The SSLE is a promising approach to exchange knowledge and experience to work toward a desired change. This study suggested that this approach could gain robustness and credibility adopting a validated and systematic methodology. Furthermore, national and international funds improve availability of and accessibility to learning on the SSLE.

 learning exchange; South-South learning exchange; peer-to-peer; South-South cooperation; knowledge exchange None This work received funding from the UNDP- UNFPA- UNICEF- WHO- World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a cosponsored programme executed by the World Health Organization through the WHO FP Accelerator Project 2019- 2022 supported by the Gates Foundation [OPP1203035]. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Introduction

The South-South learning exchange or peer-peer learning exchange refers to an interactive learning process where peers exchange knowledge and experience to work towards a beneficial change ( WHO, 2018a). These exchanges are often referred as south-to-south cooperation or knowledge exchange. The WHO’s thirteenth “General Programme of Work (2019 -2023)” ( World Health Organization, 2018b) integrated south-to-south cooperation as a strategy to develop and scale up innovative solutions for building capacities through shared learning and equitable partnerships.

The exchanges allow participants to “learn firsthand from the experience of their peers how a challenge was solved or solution implemented” ( Kumar & Watkins, 2017) and they require coordination with two peer teams (knowledge seeker and knowledge provider), a facilitator (broker) who brings the two teams together, and various stakeholders that support the work towards a change ( World Health Organization, 2018b). SSLE can inspire peers, create new ideas, implement reforms, share practical problem-solving ‘how-to’ knowledge, and foster collaboration and advocacy ( The World Bank, 2019a) – all key factors for social learning processes ( Reed et al., 2010). SSLE may be organized by international agencies, non-governmental organizations (NGOs) and governments. Different ways ( Mier-Alpano et al., 2022) such as platforms have emerged to exchange knowledge over the years ( Food and Agriculture Organization of the United Nations (FAO), 2021) and organizations have increased the opportunity to run SSLE programs to share practices and experiences in various areas, such as development, climate change, conservation management, and reproductive health and rights ( Partners In Population And Development, 2021; The World Bank, 2019a). However, few guidelines are available for conducting an exchange and are focused on specific topics like fishery learning exchanges ( Thompson et al., 2017). In addition, it is unclear if these guidelines arose from an “empirically-grounded, peer-reviewed process” ( Kumar & Watkins, 2017).

The WHO embarked on the Family Planning (FP) Accelerator project in 2019 ( World Health Organization, 2020) with the objective to improve access to quality and rights-based FP services. Under this project, ten low-income countries have participated in an SSLE. These exchanges follow a five-step approach using the preliminary version of “A step-by-step Guide to South–South learning exchanges” guide ( World Health Organization, 2018a), which allows to plan, conduct, and evaluate a SSLE. The steps include defining the need for and purpose of the learning exchange, planning the SSLE, facilitating the learning exchange, supporting implementation of the action plan and following-up after the learning exchange. An example is the SSLE between the Nepalese and Sri Lankan ministries of health, in which respective teams shared their best practices and learnings resulting in implementation of a web-based system for logistics management of FP commodities in Sri Lanka and Nepal started implementing integrated family planning services in a decentralized environment, using a lifecycle approach to improve the uptake of postpartum FP ( Kabra et al., 2022).

The peer-reviewed literature reporting SSLE experiences is limited to specific topics such as conservation management ( Bretos et al., 2017; Gardner et al., 2017; Heyman & Stronza, 2011), information system in health ( Were et al., 2019), human capacity on HIV/AIDS services ( Ivers et al., 2010), disease outbreak and health system strengthening ( Olu et al., 2017). Beyond scientific literature, results of previous SSLEs are illustrated in reports developed by organizations, such as the World Bank ( The World Bank, 2019b), the United Nations Development Programme ( United Nations Development Programme, 2017), the United Nations Office for South-South Cooperation ( United Nations Office for South-South Cooperation, 2019; United Nations Office for South-South Cooperation, 2020), and the United nations population fund ( United Nations Population Fund (UNFPA), 2018; 2021). Given the scarcity and thus great need for scientific publications on this topic Allagh et al., 2023, the intent of this research was to understand the value of SSLEs. This paper explored experts’ perspective on SSLEs, strengths, weaknesses and mechanisms leading to outcomes.

 Methods Design

We conducted a qualitative study using key informant interviews to explore the experience of participants and organizers of SSLEs. We adopted an inductive approach derived from thematic analysis. This qualitative study follows the “Consolidated Criteria for Reporting Qualitative Research COREQ” ( Tong et al., 2007) (Extended data).

 Research setting

This qualitative study is embedded into the WHO Family Planning Accelerator project, in which countries adopted a South-South learning approach. The project is overseen by the Contraceptive Unit at the Department of Sexual Reproductive Health and Rights at the WHO. The authors of this study have recently conducted a scoping review on the purposes, approaches, barriers, facilitators and outcomes of SSLE in FP ( Allagh et al., 2023), which follows the six-step methodological framework suggested by Levac et al. ( Arksey & O’Malley, 2005; Levac et al., 2010). The last step of this framework includes a stakeholder consultation that was preceded by key informant interviews with stakeholders. In this paper, we present a detailed analysis of the findings generated by these interviewees. These findings were the basis for the stakeholder consultation held at the WHO in November 2021, where stakeholders shared their experiences, enablers, barriers and lessons learnt with the goal of making future SSLEs more efficient and effective.

 Interviews

We conducted semi-structured interviews using a pre-structured interview guide (Extended file- interview guide), with open-ended questions that covered the following areas:

Process and methodology adopted during the SSLEs;

Participants’ personal and professional experiences on SSLE programs, including challenges, enablers, and lessons learnt.

We sampled purposively by reaching out to the authors or co-authors of all the studies included in our scoping review. We explained the scope of our research and requested an interview. The final number of interviews was based on the availability of expert interviewees. Additional experts were contacted using a snowball sampling technique.

 Data collection

We collected primary data by interviewing SSLE organizers and participants. Additional material was provided by interviewees. A female public health researcher (IT) conducted virtual semi-structured interviews from 1 st September 2021 to 26 th November 2021 via Google Meet. The semi-structured interviews were conducted in English. Notes were taken during the interviews. The researcher introduced herself, provided the full details of the study and requested verbal informed consent from all interviewees prior to initiating and recording the interview. IT has gained experience in qualitative research during her PhD and Post-doc in Healthcare Management, and she was providing technical support on the implementation and analysis of SSLEs at the WHO. Only one participant knew the researcher conducting the interview prior to the study. All interviewees were assured confidentiality: interviews were anonymised by assigning a number to each participant. There were no repeat interviews for the study. The interview guide was piloted during the first two interviewees. We transcribed the interviews verbatim. Transcripts were not returned to participants for their review and comments.

 Data analysis

We reviewed the transcripts and developed an initial extensive codebook (open coding), which enables the identification of emerging categories. This first round of coding was open-ended in a constant comparative process ( Braun & Clarke, 2006), after which the codebook was piloted on the first two transcripts and revised. Data were imported to a qualitative package RQDA (HUANG Ronggui (2016). RQDA: R-based Qualitative Data Analysis. R package version 0.2-8. http://rqda.r-forge.r-project.org/) that supports coding and data management. We reviewed the transcripts line-by-line and assigned codes. Categories were organized into two main themes (strengths and weaknesses) in order to answer the research question. We reviewed all the previous analysis, and sorted data to the point of saturation. Three authors coded the data with one completing the primary coding of the entire dataset (IT), which was reviewed by two researchers (RK and KA) to verify the soundness and completeness and add emerging codes. The themes were discussed and interpreted by IT and RK. Three co-authors (IT, RK and KA) addressed the organizational aspects of this study, the process of analysis and agreed on data saturation. IT, RK and JK interpreted the data.

 Ethical considerations

The WHO’s ethics review committee exempted this study from review (ERC.0003752). The study qualified for an exemption based on the Council for International Organizations of Medical Sciences (CIOMS) criteria and the WHO ERC RoP since: “public officials are interviewed in their official capacity on issues that are in the public domain”. Verbal informed consent for publication of the findings of this study and participants details was obtained.

 Results Expert characteristics

We interviewed sixteen experts from different countries and nationalities, with equal representation of female and male. Participants demonstrated varying levels of experience and performed various roles in the learning exchanges. Table 1 shows the characteristics of the sample. Three experts were not directly involved in SSLEs; however, they participated in various other research projects in collaboration with countries from the global south or in the development of the first draft of the SSLE guide. Time taken for interviews ranged from 30 to 60 minutes.

Characteristics of study participants.
Expert Name of the organization Their experience in SSLE Gender
1 United Nations Population Fund- UNFPA Implementing partner / Facilitator Male
2 Family Health International 360- FHI360 Facilitator Female
3 Blue Ventures Author of the guide on Fisheries Learning Exchanges Male
4 Strategic Consulting for Health - Rising outcomes Co-author of the WHO guide on SSLE Female
5 United Nations Population Fund- UNFPA Implementing partner / Facilitator Male
6 Nahdlatul Ulama 1 - NU Facilitator Female
7 National Family Planning Coordinating Board- BKKBN Facilitator Male
8 Partners in Population And Development, Africa Regional Office- PPD Facilitator Female
9 Partners in Population And Development- PPD Facilitator Female
10 Blue Ventures Facilitator Male
11 United Nations Population Fund- UNFPA Implementing partner / Facilitator Male
12 United Nations Population Fund- UNFPA Implementing partner / Facilitator Female
13 Partners in Population And Development- PPD Facilitator Female
14 HERA, Right to Health and Development Co-author of the WHO-guide on SS Cooperation Male
15 World Health Organization- WHO Scientist working in SRHR 2 Male
16 Knowledge Success Facilitator Female

1 Nahdlatul Ulama is the world's largest Muslim organization located in Indonesia

2 Sexual and Reproductive Health and Right

 Strengths

We identified three main strengths associated with the SSLE process: empowerment of participants, positive peer-to-peer “mind change” and convincing and powerful hands-on learning ( Figure 1).

Strengths and weakness of SSLE. Empowerment of participants

In a SSLE, participants are the key actors throughout the process; they identify the needs and purpose behind the exchange, outline the objectives, and conduct the exchange (Extended data- supplementary quotes, Table 1). Participants play a greater active role and are more likely to act on their own decisions. As reported by one facilitator, in some Muslim countries there were concerns on the compatibility of family planning with Islamic teachings, while other countries, like Indonesia, mobilized religious leaders to present their opinions and interpretations of the Islamic law. During an exchange on Family Planning among Muslim religious leaders between Indonesia and Chad, Expert 1 described the primary role of the team in advancing the exchange:

Another example on the role of participants of SSLE is reported by Expert 2 who facilitated several study tours among various regions and countries. These SSLEs aimed at scaling up the use of injectables in the hardest-to-reach communities in African countries (for example, Rwanda, Uganda). The following quote described the key role of participants:

Additionally, the facilitator supports the creation of a safe environment where team members share their own experiences. Discussions generate ideas and possible solutions, yet at the same time, they may be sensitive and lead to conflicts. Facilitators can often recognize these situations and steer around these challenges. This inclusive environment encourages diversity, connection, and relatedness. When participants feel connected, they are more prone to feel engaged and motivated, as described in the following quotes (Extended data- supplementary quotes, Table 1):

The implementation of learnings strongly relies on team, participant and stakeholder interest and engagement. For example, Expert 5 reported that “90 out of 100 participants” attend an exchange in a passive way, and have no interest in implementing the learnings or advocating for a change upon returning to their team. Should these individuals be promoted or change jobs, the benefit of the learning exchange is lost. Experts suggested that a champion with a standing influence who makes the changes required is an enabling factor for an SSLE. The strength of champions is their empowerment and engagement.

 Positive peer-to-peer “mind change”

Exchanges with peers who are managing similar challenges are more likely to lead to a positive “mind change” and innovative solutions. Peers that face similar demographic, cultural and socio-economic characteristics provide more credible problem-solving models in comparison to those who are not coping with similar challenges. Expert 1 supported an exchange between Chad and Indonesia where Chad reports some of the highest maternal mortality rates in the world and 60%–70% of the population identifies as Muslim. Indonesia was selected as peer country since it runs successful SRHR programmes and is a Muslim-majority country. After this exchange, Expert 1 from Chad reported:

A negative experience was reported by Expert 3 that facilitated an exchange between Mexican and Malagasy fishery communities. Despite the teams' dissimilar economic characteristics and needs, the SSLE was driven in response to pressure from donors. This difference affected the results of the SSLE and resulted in negative consequences.

Therefore, exchange with peers who share common characteristics is more likely to result in positive “mind changes”. Additional quotes can be found in Extended data- supplementary quotes (Table 2).

 Convincing and powerful hands-on learning

SSLE’s country tours and expert visits enables hands-on learning and for teams to explore and experience innovative solutions. This experience allows teams to engage authentically to prior knowledge and conceive new understandings. Participants are further encouraged to share and reflect on the learned diverse paradigmatic views to fully integrate ideas (Extended data- supplementary quotes, Table 3). Expert 6 provided an example where the seeker team implemented the learning after several discussions and debate. The discussion was about the gender relationship and how it translated into decision-making in the family:

Due to the COVID-19 outbreak in March 2019, study tours and field visits were suspended. This impacted SSLE as travel to other country teams and accordingly learning by seeing was interrupted. Despite the inability to have face to face discussion, most SSLEs continued via online virtual platforms. Countries found innovative ways (conference calls using internet, zoom, WhatsApp, TEAMS etc) to work within and between countries with the added benefit of enabling more people to join the exchange and reducing the cost of the SSLE. However, some experts highlighted the added value of face-to-face exchange (or a combination of both virtual and in-person) compared to online meetings, in which teams may not fully understand how a practice has been implemented. In addition, in-person meetings facilitate connection and communication, establish a common ground for dialogue, and build solidarity and empathy at greater rates than in online virtual meetings.

 Weaknesses

We identified three main weaknesses associated with SSLEs: demanding and time-consuming process (human resources, working days, costs, logistics); participants initial reluctance to SSLE approaches; absence of a systematized and internationally recognized methodology.

Demanding and time-consuming process

One of the main barriers identified by all the interviewed experts was that SSLEs require extensive resources and investment. A study tour or an expert visit requires time, funds, and human resources, as suggested by Expert 3 who was the moderator of several exchanges and oversaw their logistics (i.e. arranging flights and visas). Some experts faced several logistical issues when planning exchanges with either poor and marginalized communities or with countries currently experiencing humanitarian emergencies (conflict or war). As reported by the Indonesian Government (Expert 7), several tour visits were cancelled last minute due to conflicts or war within the country. Greater resources and more staff should be allocated to the exchanges, as illustrated in the following quote:

Additionally, the cost and resources spent on an exchange may not produce the expected results, as participants may change roles throughout the process and leave the programme prior to completion. Whenever experts work with policy makers to change policy, organizations keep engaging them and bringing them together. However, “they are very expensive people to maintain, and they keep changing. So, we may have been pursuing a policy initiative with a group of policy makers, then election coming, they lose the election and we have to start from the new ones” (Expert 8). Then, several experts reported that scarcity of resources delayed the planned activities, such as a training programme in Indonesia (Expert 7) or hindered exchanges and the follow-up activities (Expert 2 and 3) (Extended data- supplementary quotes, Table 4).

Despite requiring and utilising substantial resources, SSLE sustainability and cost-effectiveness may not be guaranteed. As reported by Expert 3, the facilitator had to convince a fishery community to participate in the exchange and had to compensate the community for the loss of value since they were not fishing during the visit exchange. Despite this, the exchange did not lead to the expected outcome - the community did not implement a conservation area. The benefit of the exchanges may not outweigh their costs.

Furthermore, interviewees highlighted that specific national South-South cooperation (SSC) budgets for SSLEs are often not provided by governments or international organizations. Exchanges are usually financed by organizations through their own funding or membership fees (Extended data- supplementary quotes- Table 4).

 Participant initial reluctance

Prior to participating in SSLEs, participants and stakeholders alike often demonstrate little interest in SSLE programs. SSLE champions need to actively advocate for an exchange program and its added benefits:

Experts encouraged the inclusion of the skeptical participants into the exchange. Once they are engaged, they would be able to convince other skeptics. Expert 3 illustrated the benefits of engaging a skeptical community in the exchange between fishing communities on re-conservation in Madagascar:

Apart from stakeholders and participants, a barrier faced by organizations in promoting SSLEs is the limited national political commitment to and operationalization of SSLE as an alternative model. In addition to that, expert 9 highlighted the absence of national policy and strategic frameworks, as well as absence of international coordination in South-South cooperation. New participants often do not have the motivation, time or willingness to take part in an exchange. Greater confidence and approaches from participants and governments may strengthen the SSLE’s organization and its operationalization.

Absence of systematized and internationally recognized methodology

Nowadays, most organizations who gain experience in conducting SSLEs draft their own internal guide and tools on how to facilitate an exchange, as illustrated in the following quotes:

The SSLE process is not systematized and is not documented. Participants do not reserve time to write their learnings and discuss, even if this step is considered valuable and helps in growing and improving the participants skills and exchange results (Extended data- supplementary quotes, Table 5).

Regarding SSLE follow-ups (tracking results and reporting), the facilitator often conducts post evaluation, such as a follow-up survey or informal feedback from the participants, often in a unstandardised way (Extended data- supplementary quotes- Table 5). Regular follow-up meetings can facilitate and support the implementation of action plans, but several experts declared that these meetings are rarely organized due to budget constraints and limited interest of participants.

During the SSLE, most experts developed an action plan or roadmap for implementing the know-how in their country/community and few of them monitored the process after exchange. The Government of Indonesia, cooperating closely with Southern partner since 1955, has established a methodology and developed tools to annually report and evaluate all the activities during and after the SSTC programmes. Other organizations have developed their internal tools, as demonstrated in the following quotes:

Even if each organization developed its instruments and tools for implementing the gained knowledge, all the experts highlighted that monitoring and evaluating (M&E) is challenging and it is often omitted, as illustrated in the following quote:

 Discussion

This study sheds light on some strengths and weaknesses of South-South learning exchanges by examining the perspective of a range of experts from different disciplines. Empowerment of participants, positive peer-to-peer “mind change”, powerful knowhow are the main strengths of the SSLE approach. Resource heavy, participants reluctancy and absence of a validated guide methodology emerged as main weaknesses of SSLE, which could impair the effectiveness of this approach. This study illustrated that SSLE is a promising and valuable tool to pass on knowledge and information from a grass-root approach.

The SSLEs’ strengths derived from two main processes previously described in the management, educational and psychological literature: experiential learning and social learning.

SSLE provides participants with hands-on, personal experiences, that are key to experimental learning. As described in the Kolb’s experimental learning model ( Kolb, 2015) and its subsequent revision ( Morris, 2019), learning consists of a four-stage cycle that includes a concrete experience, a reflective observation on the experience, conceptualization, and an active experimentation of what you have learnt. “Learning by doing” has been highlighted as a funding concept of this approach by Morrison et al. ( Morris, 2019). Learners are immersed in this learning experience that contains context-specific information, and this “hands-on” process makes learners active and empowered, as corroborated by the identified strengths. In fact, participants’ reflection on the acquired knowledge or experience, internalization and application of the knowhow are the strengths of the South-South model. This approach leads to an understanding that is different from that acquired through research, observation, books, and lessons ( Borkman, 2007). Moreover, these “hands-on” process enhances ownership, enthusiasm and leadership among participants and stakeholders.

During the exchange, participants are involved in the process of social learning ( Schusler et al., 2003). The social learning theory postulated that “social behaviour is learned by observing and imitating the behaviour of others” and suggested that “behaviour change is more likely when modelling is provided by peers than non-peers” ( Bandura & RH, 1977). Interactions with peers who are successfully coping with their experiences are more likely to result in positive behaviour change and peers are more credible role models for others. Personal interactions created a common understanding and may encourage the continuous sharing of best practices after the exchange event ( Jenkins et al., 2017). This study showed that participants and stakeholders from countries with similarity exchange knowledge and expertise in a convincing way, such as the exchange run among Indonesian and Chadian Muslim religious leaders on family planning. Peer model is a key strength of the SS learning exchange.

As SSLEs are demanding and time-consuming, they require considerable investment by facilitators and participants. Previous literature confirmed that traditional exchanges are extremely costly and time intensive ( Gardner et al., 2017; Jenkins et al., 2017). A recent experience conducted by the co-authors demonstrated SSLE can be successfully run using an online platform ( Kabra et al., 2022) with lower costs and resources. However, the interviewees reported that the virtual modality is less powerful than face-to-face sessions where participants can experience hands-on learning, as suggested by the experiential learning model. As these exchanges require significant investment to achieve desirable results, national and international commitment and funding are key to operationalising these exchanges.

The participants' and government’s reluctance to support the SSLE approach can be explained by the limited evidence on the impact of the exchanges and the implementation of learnings ( Olu et al., 2017). Most SSLE programmes are small, informal or nested in cooperation programmes ( WHO & World Health Organization, 2014), and the documentation and dissemination of results are undervalued. Our findings showed that, when in place, the monitoring, evaluation, and follow-up processes are perceived as blended or inappropriate, that can lead to further resistance and reluctance. The inappropriateness of these processes is highlighted in the “Formative evaluation of UNFPA approach to South-South and triangular cooperation” ( UNFPA Evaluation Office, 2020) and by other scholars, such as Jenkins et al. and Thompson et al. ( Jenkins et al., 2017; Thompson et al., 2017). Nevertheless, there are exceptions to the trend; for example, the Korean Development Institute and World Bank Institute assessed the knowledge exchange programs using a results-focused methodology in three case studies ( Chun & Kim, 2011). Likewise, Nepal and Sri Lanka teams developed a monitor tracker and framework to implement the action plan during a SSLE facilitated by the WHO ( Kabra et al., 2022). These exceptions show that a robust method (including the process of documenting and M&E) can lead to a more accurate demonstration of the impacts of SSLE, increased credibility, visibility to participants, governments, and funding agencies, then improved availability of and accessibility to learning on the SSLE.

We note several limitations of this study. Participants were selected from available SSLE organizers or participants contacted by the authors of this study. There were challenges in recruiting interviewees since we were solely able to contact them by email. Finally, recruitment was done by the authors of this study who work at the SRHR department, and several interviewees were SRHR experts, there may be some specific bias in recruitment.

To our knowledge, this is the first manuscript exploring the perspectives of a sample of experts on SSLE from different disciplines. The originality of this study lies in the collection of various personal and professional SSLE experiences: we sampled across various professional levels (government representatives, NGOs, communities) and captured the far-ranging capacities of SSLE application (from fishery management to family planning). An additional strength of this study stems in part from the interdisciplinary team. Co-authors of this study are from different disciplines such as healthcare management, public health, human reproduction and family planning.

This manuscript demonstrated the need for further evidence on the SSLE effectiveness. Future research should also consider the long-term impact of the SSLE and its sustainability.

 Conclusion

SSLE is a promising approach to exchanging knowledge and experience among peers. A robust and recognized methodology within all process phases is likely to help achieve the expected results, increase available evidence and demonstrate its success. However, this approach requires the support of national funds to improve its availability and accessibility.

 Data availability

In order to protect the privacy of the participants, the full data containing identifiable information has not been made publicly available. However, researchers in a related field can request additional details about the interviewees. To obtain the data, interested researchers should send an email to isotta.triulzi@santannapisa.it with the subject line 'Strengths and weaknesses of SSLE' and explain their reason for needing the data. They must also confirm that the data will not be made public or misused, and that the sharing is documented.

Extended data

Repository: Experts’ perspectives on strengths and weaknesses of the South- South Learning Exchange: a qualitative analysis. DOI: 10.6084/m9.figshare.22742180

This project contains the following extended data:

Interview Guide

Supplementary Quotes

Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).

 Reporting guidelines

Repository: Consolidated Criteria for Reporting Qualitative Research (COREQ) check list for Experts’ perspectives on strengths and weaknesses of the South- South Learning Exchange: a qualitative analysis. DOI: 10.6084/m9.figshare.23045015

Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).

 Acknowledgements

The authors of this paper would like to acknowledge all participants of this study and Prof. Giuseppe Turchetti from Scuola Superiore Sant’Anna for his helpful insights.

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Competing interests: No competing interests were disclosed.

 31 10 2023 Copyright: © 2023 Tiwari SP 2023 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve

Brief description of the article and its relevance

A 360 degree understanding of SSLE is demonstrated in the article as a result of thorough and time-consuming research. As a result, the article is well-written and informative. As a peer-driven and interactive learning process, South-South learning exchange (SSLE) aims to foster positive change by engaging participants in a peer-driven knowledge-sharing process. Despite the fact that organizations across the world have offered more opportunities for SSLE, the methods and support systems for this type of learning have not been extensively researched or documented in scientific papers. This is a thrust area for future research. This study contains a considerable amount of research on the strengths, weaknesses, and mechanisms of SSLE, as well as expert opinions. Participants' empowerment, positive peer-to-peer "mind change," and the power of hands-on learning were all observed as strengths in the successful implementation of SSLE, as stated in experts' accounts. The originality of this study is apparent, as it is a niche topic.

Major Observations

 

The study gains a higher degree of credibility when authentic and independent sources are referred to, such as the WHO, UNDP, and The World Bank, which lend credence to the study. The article is very well organized. It has logical sections that build on each other, making it easy for the reader to follow and understand. Your inclusion of key literature not only validates the points mentioned in the article, but also places the study in a broader academic context.

Using the example of SSLE between Nepalese and Sri Lankan ministries of health, it is possible to obtain a practical perspective on the topic and concepts in terms of tangible outcomes. It may be necessary to examine the experiences of countries or organizations that did not find SSLE beneficial or faced roadblocks when implementing SSLE in order to provide a balanced perspective.

It is mentioned that there were three authors who supervised the coding of the data; however, the methodology could be strengthened by clarifying how disagreements were resolved or if any challenges were encountered in maintaining consistency. If there were no disagreements or challenges during the process, a mere mention of that may also help and strengthen the methodology.

As an indicator of the quality of the output, the average length of the interviews may be useful. Even though a range of 30 to 60 minutes is provided, the average may provide a more accurate representation of how long a typical interview session took.

 Minor Observations

For the conclusion, it may be possible to improve it by summarizing the study slightly. A succinct summarization of the key findings and their implications might be helpful toward the end of the article, in order to conclude.

The conclusion points out that this approach requires national funding to improve its accessibility and availability. However, the conclusion mentioned in the ‘abstract’ mentions both national and international funding. It may be worthwhile to consider or at least mention other potential mechanisms of support, such as international partnerships or private sector collaborations, that may also help SSLE. A more detailed explanation of why funds are so important and how they can uniquely strengthen SSLE would provide greater depth to the conclusion.

While the article discusses the need for further research on SSLE's long-term impact and sustainability. The recommendations for future research may need to be made more explicit in order to ensure their success. For instance, a) Is there a specific methodology they should follow in order to accomplish this? b) Are there any knowledge gaps they need to fill? c) If so, what should they do?

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Yes

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

Yes

Are sufficient details of methods and analysis provided to allow replication by others?

Yes

Reviewer Expertise:

Knowledge sharing, Learning exchange, peer-to-peer learning

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Triulzi Isotta Scuola Superiore Sant'Anna di Studi Universitari e di Perfezionamento, Italy

Competing interests: No competing interests were disclosed.

 11 3 2024

Dear Siddhartha Paul Tiwari

Thank you very much for your positive and encouraging feedback. The queries and the suggestions you also provided were beneficial. Below is our response to your comments and the requests you make.

Major Observations

The study gains a higher degree of credibility when authentic and independent sources are referred to, such as the WHO, UNDP, and The World Bank, which lend credence to the study. The article is very well organized. It has logical sections that build on each other, making it easy for the reader to follow and understand. Your inclusion of key literature not only validates the points mentioned in the article, but also places the study in a broader academic context.

Response: Thank you for your insightful feedback. We are pleased to hear that you found the manuscript well-organized and easy to navigate, and that the inclusion of reputable sources alongside key literature, has enhanced the credibility and academic context of our study. We are grateful for your appreciation.

Using the example of SSLE between Nepalese and Sri Lankan ministries of health, it is possible to obtain a practical perspective on the topic and concepts in terms of tangible outcomes. It may be necessary to examine the experiences of countries or organizations that did not find SSLE beneficial or faced roadblocks when implementing SSLE in order to provide a balanced perspective.

Response: We have explored a range of exchanges through our interviews, and some participants shared that they did face various challenges. These insights are detailed in the results section of the manuscript, providing a comprehensive view of the diverse experiences associated with SSLE implementations.

It is mentioned that there were three authors who supervised the coding of the data; however, the methodology could be strengthened by clarifying how disagreements were resolved or if any challenges were encountered in maintaining consistency. If there were no disagreements or challenges during the process, a mere mention of that may also help strengthen the methodology.

Response: Thank you for this comment. We have reviewed the methodology accordingly. Please check it.

As an indicator of the quality of the output, the average length of the interviews may be useful. Even though a range of 30 to 60 minutes is provided, the average may provide a more accurate representation of how long a typical interview session took.

Response: We have incorporated this information within the revised manuscripts. The average length of the interview was 50 minutes.

Minor Observations

For the conclusion, it may be possible to improve it by summarizing the study slightly. A succinct summarization of the key findings and their implications might be helpful toward the end of the article, in order to conclude.

Response: We have rewritten the conclusion summarizing the key findings and their implications, as per your suggestions.

The conclusion points out that this approach requires national funding to improve its accessibility and availability. However, the conclusion mentioned in the ‘abstract’ mentions both national and international funding. It may be worthwhile to consider or at least mention other potential mechanisms of support, such as international partnerships or private sector collaborations, that may also help SSLE. A more detailed explanation of why funds are so important and how they can uniquely strengthen SSLE would provide greater depth to the conclusion.

Response: Thank you for your constructive feedback on the significance of funding for SSLE. We appreciate this chance to clarify and deepen our discussion on this topic. In response, we have updated the discussion section to offer a more detailed examination of the various types of funding available and their pivotal role in strengthening SSLE initiatives. This includes an exploration of national and international funding sources, as well as the potential for support through international partnerships and private-sector collaborations. Additionally, we have revised the abstract to ensure consistency and clarity.

While the article discusses the need for further research on SSLE's long-term impact and sustainability. The recommendations for future research may need to be made more explicit in order to ensure their success. For instance, a) Is there a specific methodology they should follow in order to accomplish this? b) Are there any knowledge gaps they need to fill? c) If so, what should they do?

Response: Thank you for this comment. We have enriched the paragraph at the end of the discussion, and we have highlighted the need for more research on developing consistent guidelines, frameworks and evaluation systems in SSLE.

 10.21956/gatesopenres.16024.r34852 Reviewer response for version 1 Hirst Jane 1 Referee https://orcid.org/0000-0002-0176-2651 Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, England, UK

Competing interests: No competing interests were disclosed.

 29 9 2023 Copyright: © 2023 Hirst J 2023 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

This is an interesting article with important learnings around south-south learning exchange.

It would be useful to state what levels the SSLE explored in this paper relate to: e.g. government to government; subnational level to subnational; NGO to NGO or community to community, or combinations? Could this be a factors in success or failure of the program?

One of the comments refers to power imbalance being a limiting factor in the success of the SSLE (the Mexico-Malagasi fishing example). Could the authors comments on the level of engagement that the case studies they explore relate to and whether that had any bearing on the perceived or actual impact of the exchange.

The authors come from a health background, specifically in contraception. Are there are factors which make SSLE in this sector any more of less likely to be successful compared to the other sectors?

It would be useful for someone not in this field to define the different between a participant and a stakeholder in SSLE.

The lack of an agreed framework for SSLE is listed as a limitation, yet it appeared several of the larger multilaterals or NGOs in this paper have their own frameworks, including WHO. Are these frameworks not known or not used? It would be useful in the discussion to consider what is needed to move beyond this situation. Is the situation limited to certain sectors, or is it common across all?

The participants involved in the interviews were mostly facilitators of the process. Are there any similar studies looking at the perspectives of the peer teams or stakeholders? The views of the facilitators are valuable, however only represent one dimension to the experience.

In table 1, it would be helpful to list the years’ experience or number of SSLE each participant had been involved in to give an idea or how “expert” the Experts actually were

 In the introduction it would be useful to give the headline finding of your scoping review in this aera, how many programs did you identify and the key message

As the objective is stated that this is the final step in the scoping review process as key informant interviews with stakeholders, please justify the inclusion of interviewees not in the FP space (i.e. fisheries)

Were the stakeholders who attended the 2021 WHO consultation the same as the interviewees in this paper? It is a little unclear which stakeholder you are referring to.

What were the limitations selecting only authors identified in your scoping review? Presumably most SSLE don’t result in a peer-reviewed publication so could this have introduced bias? How did you ensure geographic representation in this exercise? Please state in the description of the participants how many were LMIC (i.e. “South”) based.

In the data collection section, more should be included to indicate reflexivity of the lead researchers and her own personal positionality and experience of SSLE, including whether she was commissioned/paid to do this work.

 After the interview guide piloting were any changes made? Did the interviewer adapt the interview guide based on the findings of previous interviews?

Could only conducting the interviews in English been a limitation for this process?

From the case studies described, I was left a bit unclear about what comprises a SSLE. Some seemed to have study tours, others a facilitated session. Is there a clear definition of what constitutes a SSLE and how long it needs to be at a minimum? Are all SSLE bilateral, or are some trilateral, multilateral, regional etc. Is a regional conference a SSLE for example or is what distinguishes it a predefined implementation agenda?

COVID 19 outbreak started in March 2020 globally, not March 2019

Zoom, WhatsApp and Microsoft Teams are all brand names and should be capitalised and if appropriate a TM or company name indicated

Cost is always a limitation. For the reader less familiar with this space, it would be useful to describe the range of sources and scale of funding the experts used for these activities.

What would help really bring this paper together would be a box of key recommendations for those conducting and planning SSLE based on your findings.

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Not applicable

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

Yes

Are sufficient details of methods and analysis provided to allow replication by others?

Partly

Reviewer Expertise:

Global women's health, health systems

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Triulzi Isotta Scuola Superiore Sant'Anna di Studi Universitari e di Perfezionamento, Italy

Competing interests: No competing interests were disclosed.

 11 3 2024

Dear Prof. Jane Hirst,

We greatly appreciate the time and effort you've dedicated to providing thoughtful comments and suggestions on our study. We have dedicated our efforts to address your concerns and hope that our revisions reflect the high standards you uphold.

We look forward to any further suggestions you may have that can enhance our study.

Best wishes

1.           It would be useful to state what levels the SSLE explored in this paper relate to: e.g. government to government; subnational level to subnational; NGO to NGO or community to community, or combinations? Could this be a factor in success or failure of the program?

Response: Thank you for this comment.  The exchange was a combination of staff from different levels, government, Sub national level staff, academia, NGO . We have enriched Table 1.Characteristic of study participants with additional information and we have included further information on the type of the exchanges and main participants that indicate the level of each SSLE.

2.           One of the comments refers to power imbalance being a limiting factor in the success of the SSLE (the Mexico-Malagasi fishing example). Could the authors comments on the level of engagement that the case studies they explore relate to and whether that had any bearing on the perceived or actual impact of the exchange.

Response: The level of participant engagement in the SSLEs plays a crucial role in facilitating the exchange of information and implementing the learnings.  In most SSLE s ministry of staff has been active participant and this actually worked as a motivating factor. As highlighted in our manuscript, empowering participants emerges as a key strength of these exchanges. Participants who showed high levels of engagement (referred to as champions) are more motivated to have advocate for change upon returning to their team.

3.           The authors come from a health background, specifically in contraception. Are there factors which make SSLE in this sector any more of less likely to be successful compared to the other sectors?

Response: Thank you for your comment. Considering the factors that may influence the success of the South-South Learning Exchange (SSLE) in the field of contraception, we recognised the challenges posed by cultural and religious factors. Contraception is closely intertwined with personal beliefs and practices, often involving couples and communities. Navigating these sensitive and complex dynamics is essential for effective knowledge exchange in this sector. While we recognize that other sectors such as agriculture and fishing have their own challenges, we believe that addressing the specific cultural and interpersonal aspects of contraceptive practices requires a standardised yet tailored and culturally competent approach within the SSLE. Thank you for highlighting this important aspect.

4.           It would be useful for someone not in this field to define the difference between a participant and a stakeholder in SSLE.

Response: Thank you for raising this important point. In the context of the South-South Learning Exchange (SSLE), defining the difference between a participant and a stakeholder is crucial for clarity. A participant typically refers to an individual or group directly engaged in the learning exchange activities, such as attending visit tours, study tours, virtual meetings within the SSLE framework. On the other hand, a stakeholder encompasses a broader range of individuals or organizations who support or have an interest in, or may be affected by, the outcomes of the SSLE. This could include policymakers, government agencies, non-governmental organizations, community representatives, and other relevant entities whose involvement and influence extend beyond direct participation. We have clarified on these distinctions in our revised manuscript (introduction) to ensure a clear understanding for readers beyond the field. Thank you for highlighting the need for this clarification.

5.            The lack of an agreed framework for SSLE is listed as a limitation, yet it appeared several of the larger multilaterals or NGOs in this paper have their own frameworks, including WHO. Are these frameworks not known or not used? It would be useful in the discussion to consider what is needed to move beyond this situation. Is the situation limited to certain sectors, or is it common across all?

Response: Several agencies and non-governmental organizations, the World Health Organization (WHO) included, have embarked on SSLEs employing a variety of methodologies and frameworks. Drawing on this diversity of approaches, our research introduces a five-step methodology specifically designed to enhance the effectiveness and impact of SSLEs.

Our methodology places a strong emphasis on the preparation phase, particularly on the prioritization of the learning question, which we believe is crucial for setting the stage for a successful exchange. This initial step ensures that all participants are aligned and focused on the objectives of the exchange. Furthermore, we give considerable attention to the phases following the exchange. This includes post-exchange implementation, follow-up, and comprehensive documentation of the outcomes and lessons learned. Our approach is designed not only to maximize the immediate benefits of the exchange for the participating entities but also to provide a valuable resource for others in the field.

6.           The participants involved in the interviews were mostly facilitators of the process. Are there any similar studies looking at the perspectives of the peer teams or stakeholders? The views of the facilitators are valuable, however only represent one dimension to the experience.

Response: Thank you for this comment. In response to your inquiry about similar studies that explore the perspectives of peer teams or stakeholders, we identified several pieces of literature, including a study on SSLE in marine conservation by Gardner et al. (2017), where the views of peer teams were examined through interviews. We recognize the importance of capturing a multi-dimensional perspective and have acknowledged this limitation in the discussion section of our revised manuscript.

7.           In table 1, it would be helpful to list the years’ experience or number of SSLE each participant had been involved in to give an idea or how “expert” the Experts actually were

Response: Thank you for the suggestion. We appreciate your feedback on incorporating details about the years of experience or the number of SSLE each participant has been involved in, to shed light on their expertise level. We have enriched Table 1 with additional information on the SSLE initiatives implemented by our sample of experts, including their years of experience (< 5 years; >5 years). Even if we did not inquire about the exact number of years, all the interviewees were senior professionals, demonstrating an extensive experience in this sectors.

8.            In the introduction it would be useful to give the headline finding of your scoping review in this aera, how many programs did you identify and the key message

Response: We have reviewed the introduction accordingly.

9.           As the objective is stated that this is the final step in the scoping review process as key informant interviews with stakeholders, please justify the inclusion of interviewees not in the FP space (i.e. fisheries)

Response: We have expanded our sample deliberately to encompass a wider scope, focusing on the SSLE process, methodology, and approach. These aspects extend beyond the confines of the FP space, and by including stakeholders from diverse fields, we aim to gain insights that contribute to a comprehensive understanding. Our goal is to explore best practices, and potential lessons that may not be confined to a specific sector. We thought that this approach allows us to enrich our scoping review with a more inclusive and holistic perspective.

10.        Were the stakeholders who attended the 2021 WHO consultation the same as the interviewees in this paper? It is a little unclear which stakeholder you are referring to.

Response: Yes, all of them were invited at the 2021 WHO consultation, but some of them attended it.

11.        What were the limitations selecting only authors identified in your scoping review? Presumably most SSLE don’t result in a peer-reviewed publication so could this have introduced bias?

Response: Our scoping review research strategy adopted a broad approach, and we included various type of publications identified via databases, registries and websites, and organizations. This type of research enables us to include participants from various fields, even if their experiences did not culminate in a peer-reviewed publication. However, we may overlooked individuals involved in SSLEs, potentially introducing a selection bias into our research, introducing a bias. We have clarified it in the text (section Methodology, Interviews ) and add it in the limitation section.

12.        How did you ensure geographic representation in this exercise? Please state in the description of the participants how many were LMIC (i.e. “South”) based.

Response: We have added a column in the table 1, country of birth, and a sentence in the results (Expert characteristics).

13.        In the data collection section, more should be included to indicate reflexivity of the lead researchers and her own personal positionality and experience of SSLE, including whether she was commissioned/paid to do this work.

Response: We have reviewed the text accordingly. This study was not commissioned and paid by the WHO.

14.        After the interview guide piloting were any changes made? Did the interviewer adapt the interview guide based on the findings of previous interviews?

Response: In response to your comment, only a few changes were made to the interview guide following the initial couple of interviews. These adjustments have been duly noted and incorporated into the manuscript, specifically in the Methodology section under data collection

15.        Could only conducting the interviews in English been a limitation for this process?

Response: While conducting interviews exclusively in English may have been a potential limitation for our research, it's essential to note that the vast majority of participants were able to engage effectively. However, we did encounter challenges with this sample of experts. We have mentioned this in the Discussion section (limitations).

16.        From the case studies described, I was left a bit unclear about what comprises a SSLE. Some seemed to have study tours, others a facilitated session. Is there a clear definition of what constitutes a SSLE and how long it needs to be at a minimum? Are all SSLE bilateral, or are some trilateral, multilateral, regional etc. Is a regional conference a SSLE for example or is what distinguishes it a predefined implementation agenda?

Response: Thank you for your thoughtful questions about SSLEs. Our scoping review (Allagh KP, 2023) captures four types of approaches including study tours (reciprocal, non-reciprocal), virtual exchange, expert visits, and mixed method exchange (study tour and expert visits; virtual reciprocal exchange), and it has emphasized that SSLEs can be bilateral, trilateral, or multilateral. SSLEs can manifest in bilateral, trilateral, multilateral, or even regional formats. The duration of SSLEs is not universally predefined, allowing for flexibility to tailor the exchanges according to the specific requirements and objectives of the participants. This information has been included in the revised manuscript.

17.        COVID 19 outbreak started in March 2020 globally, not March 2019

Response: This is corrected.

18.        Zoom, WhatsApp and Microsoft Teams are all brand names and should be capitalised and if appropriate a TM or company name indicated

Response: We have modified the text accordingly.

19.        Cost is always a limitation. For the reader less familiar with this space, it would be useful to describe the range of sources and scale of funding the experts used for these activities.

Response: Thank you for your suggestion. In response, we have expanded the discussion section to detail the variety of funding sources utilized for these exchanges. However, we must note that the specific amounts of funding employed by each agencies/experts were not requested during the interview. This information has been included in the discussion.

20.        What would help really bring this paper together would be a box of key recommendations for those conducting and planning SSLE based on your findings.

Response: We have added a box of key recommendations at the end of the results, as per your suggestions.