Rethinking health systemsstrengthening:key systems thinking tools andstrategies for transformational change

Rethinking health systemsstrengthening:key systems thinking tools andstrategies for transformational change

Systems thinking and Adaptive complexsystem

Systems thinking

Systems thinking offers a lens of enquiry through which asystem may be viewed as more than the sum of its parts.

Systems thinking emphasizes the importance ofrelationships and the unpredictable behaviours that arisefrom interactions between system components

An iterative learning process in which systems viewed asa holistic, broad, long-term, dynamic, that reinventing ourpolicies and institutions accordingly’

Systems thinking offers a lens of enquiry through which asystem may be viewed as more than the sum of its parts.

Systems thinking emphasizes the importance ofrelationships and the unpredictable behaviours that arisefrom interactions between system components

An iterative learning process in which systems viewed asa holistic, broad, long-term, dynamic, that reinventing ourpolicies and institutions accordingly’

Systems thinking

These new modes of working must seek to integrateacross disciplines, hierarchies, departments andspecialties.

Policy makers must identify appropriate partners, growrelationships and build local capacity.

They must learn from feedback, adjust, adapt, dissolve andregenerate to meet the changing needs of health systems.

These new modes of working must seek to integrateacross disciplines, hierarchies, departments andspecialties.

Policy makers must identify appropriate partners, growrelationships and build local capacity.

They must learn from feedback, adjust, adapt, dissolve andregenerate to meet the changing needs of health systems.

a novel opportunity for synergy

Health systems strengthening have been fragmented andunsystematic that underpinned disease-specificprogrammes.

The disease-specific programmes have been variablysuccessful: Immunizations anti-retroviral treatment for AIDS directly observed short-course treatment (DOTS) for tuberculosis,

Health systems strengthening have been fragmented andunsystematic that underpinned disease-specificprogrammes.

The disease-specific programmes have been variablysuccessful: Immunizations anti-retroviral treatment for AIDS directly observed short-course treatment (DOTS) for tuberculosis,

A novel opportunity for synergy

However, the long-term impact of these programmes onhealth systems is unclear, with unsystematic evidence forpositive and negative effects.

This realization of limited documented positive effects onhealth systems of targeted health investments has led to arenewed interest in ‘health systems strengthening’ (HSS)

HSS emphasis on principles such as financing nationalhealth strategies, integration, local ownership andsustainability.

However, the long-term impact of these programmes onhealth systems is unclear, with unsystematic evidence forpositive and negative effects.

This realization of limited documented positive effects onhealth systems of targeted health investments has led to arenewed interest in ‘health systems strengthening’ (HSS)

HSS emphasis on principles such as financing nationalhealth strategies, integration, local ownership andsustainability.

A novel opportunity for synergy

However HSS approaches too often focus on a narrowaspect of the health system such as family planning,community health workers, financing schemes orparticular interventions.

Systems thinking can complement and enrich theprevailing reductionist approaches to health improvementand the current HSS movement, by improving healthpractice, education, research and policy.

However HSS approaches too often focus on a narrowaspect of the health system such as family planning,community health workers, financing schemes orparticular interventions.

Systems thinking can complement and enrich theprevailing reductionist approaches to health improvementand the current HSS movement, by improving healthpractice, education, research and policy.

A novel opportunity for synergy

A paradigm shift towards systems thinking will strengthenhealth systems effectively around the globe therebyleading to improved health outcomes.

Professionals will need to gradually transition away fromexclusively applying reductionist health approaches, whilesimultaneously embracing systems thinking and widelyaccepted guiding principles.

A paradigm shift towards systems thinking will strengthenhealth systems effectively around the globe therebyleading to improved health outcomes.

Professionals will need to gradually transition away fromexclusively applying reductionist health approaches, whilesimultaneously embracing systems thinking and widelyaccepted guiding principles.

Systems thinking to transform health practice Systems thinking to transform health education Systems thinking to transform health research Systems thinking to transform health policy

Systems thinking to transform healthpractice

Practitioners on the ground are constrained: inter alia,regulatory policies, social norms, varying levels ofevidence to support interventions, erroneousassumptions commercial pressures, conflicts of interests,and inadequate education and training.

The degree of success of health producers depends onability to collaborate with other key stakeholders arounda shared vision. Organizations have to continuouslyworking together to create a common future.

Practitioners on the ground are constrained: inter alia,regulatory policies, social norms, varying levels ofevidence to support interventions, erroneousassumptions commercial pressures, conflicts of interests,and inadequate education and training.

The degree of success of health producers depends onability to collaborate with other key stakeholders arounda shared vision. Organizations have to continuouslyworking together to create a common future.

Systems thinking to transform healthpractice

Health professionals will need to be able to set commongoals and targets with patients, service users and relevantstakeholders, and ensure that each group or individual isproperly informed and engaged.

Evidence and explicit knowledge need to be integratedwith tacit knowledge of stakeholders within the workingdynamic of the health team.

Health professionals will need to be able to set commongoals and targets with patients, service users and relevantstakeholders, and ensure that each group or individual isproperly informed and engaged.

Evidence and explicit knowledge need to be integratedwith tacit knowledge of stakeholders within the workingdynamic of the health team.

Systems thinking to transform health practice Systems thinking to transform health education Systems thinking to transform health research Systems thinking to transform health policy

Systems thinking to transform healtheducation

The use of a systems thinking approach in healtheducation to address complex problems may bring aboutmore creative and sustainable solutions to inadequateperformance of health systems globally.

Systems thinking trained public health professionalsaddress the complex challenges by designing effectiveinterventions to maximize the positive health outcomes,while minimizing unintended negative consequences.

The use of a systems thinking approach in healtheducation to address complex problems may bring aboutmore creative and sustainable solutions to inadequateperformance of health systems globally.

Systems thinking trained public health professionalsaddress the complex challenges by designing effectiveinterventions to maximize the positive health outcomes,while minimizing unintended negative consequences.

Systems thinking to transform healtheducation

It will require not only changes in curricular content, butalso a need to base teaching and learning within thereality of a continuously changing health system on theground.

Ongoing learning must occur at all levels of the healthsystem and academic centers should extend training intothe health systems within their communities.

It will require not only changes in curricular content, butalso a need to base teaching and learning within thereality of a continuously changing health system on theground.

Ongoing learning must occur at all levels of the healthsystem and academic centers should extend training intothe health systems within their communities.

Systems thinking to transform health practice Systems thinking to transform health education Systems thinking to transform health research Systems thinking to transform health policy

Systems thinking to transform healthresearch

Health researchers have traditionally sought to answer aspecific question at a particular point in time bycontrolling for all other variables as much as possible;

Research in systems modelling and simulation has shownpromise in capturing the complex, dynamic nature ofhealth challenges.

Health researchers have traditionally sought to answer aspecific question at a particular point in time bycontrolling for all other variables as much as possible;

Research in systems modelling and simulation has shownpromise in capturing the complex, dynamic nature ofhealth challenges.

Systems thinking to transform healthresearch

Systems thinking promotes the importance of multileveland multi-actor methods (e.g. system dynamics modelling,social network analyses)to understand system behaviours.

Qualitative health research can help understand healthsystems complexities: the behaviours of actors, and theperceptions and culture of the people related to healthsystems

Systems thinking promotes the importance of multileveland multi-actor methods (e.g. system dynamics modelling,social network analyses)to understand system behaviours.

Qualitative health research can help understand healthsystems complexities: the behaviours of actors, and theperceptions and culture of the people related to healthsystems

Systems thinking to transform healthresearch

However, this traditional, reductionist approach, toresearch widens the gap between knowledge and practice.

A paradigm shift is needed in knowledge translation thattakes a systems view by: embracing complexity inresearch; considering local context; widely applyingcommunity-based participatory and action researchmethods;

A shift from the current ‘research-to-practice’ model toan ‘applied research paradigm,

However, this traditional, reductionist approach, toresearch widens the gap between knowledge and practice.

A paradigm shift is needed in knowledge translation thattakes a systems view by: embracing complexity inresearch; considering local context; widely applyingcommunity-based participatory and action researchmethods;

A shift from the current ‘research-to-practice’ model toan ‘applied research paradigm,

Systems thinking to transform health practice Systems thinking to transform health education Systems thinking to transform health research Systems thinking to transform health policy

Systems thinking to transform health policy

Health policies result from a complex interplay betweensocial, political, physical, ecological, biological, cultural,technical and economic factors

Negotiating the inputs from these various sources oftenis done under temporal and resource pressures,complicated by political and social upheaval.

Health policies result from a complex interplay betweensocial, political, physical, ecological, biological, cultural,technical and economic factors

Negotiating the inputs from these various sources oftenis done under temporal and resource pressures,complicated by political and social upheaval.

Systems thinking to transform health policy

Policy makers too often approach health systems from amechanistic perspective, assuming that implementing aparticular policy will lead to a predictable change in thebehaviour of local actors thereby ignoring theinteractions between them.

This line of thinking leads increasingly to detailedincentives and regulations from the top down, a so-called‘command and control’ approach to policy.

Policy makers too often approach health systems from amechanistic perspective, assuming that implementing aparticular policy will lead to a predictable change in thebehaviour of local actors thereby ignoring theinteractions between them.

This line of thinking leads increasingly to detailedincentives and regulations from the top down, a so-called‘command and control’ approach to policy.

Systems thinking to transform health policy

Health system problems usually, cannot be broken down,they are not just the parts but how they are put together,behaviours are unpredictable and non-linear ‘effects’ arefelt.

Many well-intentioned policies fail to address theproblems they are designed to solve, and in attempting todo so, actually generate new ones.

Health system problems usually, cannot be broken down,they are not just the parts but how they are put together,behaviours are unpredictable and non-linear ‘effects’ arefelt.

Many well-intentioned policies fail to address theproblems they are designed to solve, and in attempting todo so, actually generate new ones.

Systems thinking to transform health policy

The tendency for these policies to be defeated by theresponse of the system to the policy itself is known as‘policy resistance’.

The command and control approach too often results inunintended consequences such as duplication of services,inefficiencies, policy resistance, erosion of capacity,dependence and other negative effects:

‘gaming the system’ to maximize individual gain at the expense of thelarger system.

The tendency for these policies to be defeated by theresponse of the system to the policy itself is known as‘policy resistance’.

The command and control approach too often results inunintended consequences such as duplication of services,inefficiencies, policy resistance, erosion of capacity,dependence and other negative effects:

‘gaming the system’ to maximize individual gain at the expense of thelarger system.

Systems thinking to transform health policy

What is needed is a way of thinking that recognizes that partsare not disconnected from the whole and that dynamicrelationships exist which shape, and are shaped, by theirenvironment.

Understanding evolutionary design of the health system byobserving and identifying local intervention successes throughfeedback loops, the system can be optimized over time topromote long-term positive health effects.

Embracing uncertainty in health decisions can facilitate thedesign of policy to structure complex adaptive systems.

What is needed is a way of thinking that recognizes that partsare not disconnected from the whole and that dynamicrelationships exist which shape, and are shaped, by theirenvironment.

Understanding evolutionary design of the health system byobserving and identifying local intervention successes throughfeedback loops, the system can be optimized over time topromote long-term positive health effects.

Embracing uncertainty in health decisions can facilitate thedesign of policy to structure complex adaptive systems.

Strengthening health systemsthrough networks: the need formeasurement and feedback

Strengthening health systemsthrough networks: the need formeasurement and feedback

Role for networks Interorganizational networks have emerged at the global

level, as well as at national and subnational levels, asimportant strategies for organizing human effort in asystems-thinking mode of operation.

The rise in network popularity has come largely from therecognition that money alone cannot sufficiently improvethe quality of health systems, and that the major healthproblems facing societies are unlikely to be successfullyaddressed by individual organizations acting in Isolation.

Interorganizational networks have emerged at the globallevel, as well as at national and subnational levels, asimportant strategies for organizing human effort in asystems-thinking mode of operation.

The rise in network popularity has come largely from therecognition that money alone cannot sufficiently improvethe quality of health systems, and that the major healthproblems facing societies are unlikely to be successfullyaddressed by individual organizations acting in Isolation.

Role for networks

Network structures represent a broad set of collaborativeapproaches that are useful for bringing stakeholders together.

Networks are ‘a set of nodes and the set of ties representingsome relationship, or lack of relationship, between the nodes’

Using network analyses provide studying organizationalnetworks and the ways that they collaborate to impact health;and supporting leaders who strengthen the link betweenresearch and practice.

Network structures represent a broad set of collaborativeapproaches that are useful for bringing stakeholders together.

Networks are ‘a set of nodes and the set of ties representingsome relationship, or lack of relationship, between the nodes’

Using network analyses provide studying organizationalnetworks and the ways that they collaborate to impact health;and supporting leaders who strengthen the link betweenresearch and practice.

Role for networks

The study of networks has provided important learningfor how people and groups might work together either inspontaneously evolving networks, or through formalestablishment of network partnerships.

Appropriate governance structures are needed at global,national and subnational levels to foster commitmentamong network members and promote accountabilitythrough shared measures of network performance.

The study of networks has provided important learningfor how people and groups might work together either inspontaneously evolving networks, or through formalestablishment of network partnerships.

Appropriate governance structures are needed at global,national and subnational levels to foster commitmentamong network members and promote accountabilitythrough shared measures of network performance.

Measuring network indices Identifying the optimal approach to developing and

supporting interorganizational collaborations in LMICshas been highlighted as a primary challenge for healthsystems strengthening activities.

With only modest evidence that collaborative networksare effective, research is needed urgently to ensurecurrent and future network efforts do not become ‘yetanother ineffective talking shop that [do] more harm thangood.

Identifying the optimal approach to developing andsupporting interorganizational collaborations in LMICshas been highlighted as a primary challenge for healthsystems strengthening activities.

With only modest evidence that collaborative networksare effective, research is needed urgently to ensurecurrent and future network efforts do not become ‘yetanother ineffective talking shop that [do] more harm thangood.

Measuring network indicesTo increase the role and value of networks in health

systems, a clearer understanding of two issues is required:

How should network performance be measured in waysthat promote broad stakeholder learning?

How can these measures be built into appropriateaccountability structures in order to strengthen networkand health system performance?

To increase the role and value of networks in healthsystems, a clearer understanding of two issues is required:

How should network performance be measured in waysthat promote broad stakeholder learning?

How can these measures be built into appropriateaccountability structures in order to strengthen networkand health system performance?

Measuring network performance

As such, an evaluative approach built on systems thinkingconcepts is required for recognizing the complex factorsinfluencing network performance and the dynamic, non-linear and interrelated nature of network activities.

Measures of structure (such as gained through socialnetwork analyses) may be important for giving insightsinto network development, relationship strength andmember involvement.

As such, an evaluative approach built on systems thinkingconcepts is required for recognizing the complex factorsinfluencing network performance and the dynamic, non-linear and interrelated nature of network activities.

Measures of structure (such as gained through socialnetwork analyses) may be important for giving insightsinto network development, relationship strength andmember involvement.

Community level outcomes may be measured throughthe contributions made by the network to communities,including costs incurred, public perceptions of networkperformance, and aggregate indicators of health status inthe population.

Network level effectiveness is more concerned with thelegitimacy of the network itself and may be measured byrelationship strength and member involvement.

Community level outcomes may be measured throughthe contributions made by the network to communities,including costs incurred, public perceptions of networkperformance, and aggregate indicators of health status inthe population.

Network level effectiveness is more concerned with thelegitimacy of the network itself and may be measured byrelationship strength and member involvement.

Improving feedback and accountability

Accountability structures may be best seen as usefulsources of feedback for informing strategy and action.

Framed by systems thinking, the feedback mechanismsthrough which accountability may be generated requireconsideration of: How to use what data, by whom and when; What proportion of data to use; How to direct this use; How to ensure data are used appropriately and effectively;

Accountability structures may be best seen as usefulsources of feedback for informing strategy and action.

Framed by systems thinking, the feedback mechanismsthrough which accountability may be generated requireconsideration of: How to use what data, by whom and when; What proportion of data to use; How to direct this use; How to ensure data are used appropriately and effectively;

Improving feedback and accountability

Contextual factors will likely lead to differing feedbackstructures in networks managed by participantgovernance, shared governance, lead organizationgovernance, or those with appointed administrativeorganizations

Therefore feedback structures need to ensure data arenot only reliable and valid, but that they are relevant andactionable for users in different network settings.

Contextual factors will likely lead to differing feedbackstructures in networks managed by participantgovernance, shared governance, lead organizationgovernance, or those with appointed administrativeorganizations

Therefore feedback structures need to ensure data arenot only reliable and valid, but that they are relevant andactionable for users in different network settings.