Systems thinking for
health systems strengthening Taghreed Adam, MD, PhD
Alliance for Health Policy and Systems Research, WHO
Course in Health systems and policy Master Programme in Public Health
Karolinska Institutet, Stockholm, 2 December, 2011
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Good understanding of:
– Main characteristics of complex systems
– Health systems actors and their role/power
– What is systems thinking and what are its basic skills
– Why systems thinking is very important for health systems
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Initiation in:
– How to think about the intended and unintended effects of health policies using a systems thinking approach
Health systems
z Key social goal…
z Improve health by
z average level of population health
z health inequities
“All organizations, people and action whose
primary intent is to promote, restore or
maintain health”
WHO, 2007Why renewed interest in health systems?
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Still enormous disease preventable deaths, particularly
in LMICs
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MDGs deadline approaching but not much progress
made
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Despite massive increase in funding, systems are not
delivering fast enough
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Problems with scaling up essential life saving
interventions
Health systems are complex!
E.g. Architecture of drug supply sub-system in Kenya
Foundations
System building blocks and values
Underlying health systems framework
INPUTS & PROCESSES
Governance, leadership, regulatory issues Finances Human resources Infrastructure Procurement logistics & supplies Information
INPUTS & PROCESSES
Governance, leadership, regulatory issues Finances Human resources Infrastructure Procurement logistics & supplies Information OUTPUTS Strengthened system Improved services • efficiency • access • availability • affordability • acceptability • quality • safety OUTPUTS Strengthened system Improved services • efficiency • access • availability • affordability • acceptability • quality • safety OUTCOMES Increased • coverage • utilization • responsiveness OUTCOMES Increased • coverage • utilization • responsiveness IMPACTS Improved • survival • nutrition • equity Reduced • morbidity • impoverishment due to health expenditures IMPACTS Improved • survival • nutrition • equity Reduced • morbidity • impoverishment due to health expenditures
OTHER DETERMINANTS OF HEALTH
(Economic, Social, Political, Environmental)
OTHER DETERMINANTS OF HEALTH
(Economic, Social, Political, Environmental)
Health Systems: More than the building blocks
How do we work them together for a more
high performance system?
So what is
Four revolutions
z “There are four revolutions currently underway that will transform health and health systems. These are:
z Life sciences
z Information and communication technology
z Social justice and equity; and
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Systems thinking to transcend complexity”
Systems thinking
z Systems thinking gives deeper insights into:
z how a system works,
– why it has problems,
– how it can be improved
Characteristics of all complex systems
And ….
• nest sub-systems within them • but are part of larger systems
Example
System thinking skills
Loop thinking Linear thinking
concentrating on causality and how behaviour is generated
concentrating on factors that influence or correlate
View causality as an on-going process with feedback influencing causes
view causality running in one direction
Operational thinking Factors thinking
knowledge from understanding contexts of relationships
knowledge from understanding details
Forest-thinking Tree-by-tree thinking
responsibility for behaviour from internal actors and rules
behaviour as externally driven
Systems as cause Systems as effect
focus on patterns of behaviour focus on events
Dynamic thinking Static thinking
Systems thinking approach
Usual approach
The role and power of
systems stakeholders
How stakeholder perspectives can vary
A health system is ….
Case study
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Why there was low enrolment of the voluntary
community health insurance scheme in Tanzania?
– Supposed to cover the rural population (80% of total population)
– After 10 years, only 10% enrolled were 70% were expected to do so
z Source: Kamuzora and Gilson. Factors influencing
implementation of the Community Health Fund in Tanzania. Health Policy and Planning 2007;22:95–102
What was the policy?
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Payment and benefits:
z Members pay fixed annual fee per household but no co-payment when using services
z Households unable to pay the fee are, in principle, entitled to an exemption.
z Households not joining the CHF pay user fees when attending health facilities.
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Districts should:
z manage the fund (monitoring, mobilizing and administering funds, setting exemption policy and targets).
z ensure quality of care and facility supervision.
z Sub-district mobilize communities to join, award exemptions and develop community health plans for submission to district.
What happened?
z Interviews with district managers indicated a negative attitude towards exemption; arguments:
– exemptions are difficult to implement
– since the number of households qualifying for exemption was large
– exemption would erode the CHF’s financial base
– exemptions are untenable
z They all blamed the central government for not addressing the financial sustainability of the CHF
z They ignored guidelines from the central government requiring them to develop exemption criteria; arguments:
– it was the responsibility of the village
– did not have clear exemption criteria
What happened? (2)
z District managers discouraged exemption proposals coming from the communities; requests were either refused or given no
feedback.
z They considered the policy as an additional separate activity from their routine work—like a project imposed on them
z They did not ensure supervision or availability of drugs and medicines
z They did not inform people about the exemption policy or the value of joining community health funds
What have we learnt?
z Top down versus bottom up policy making—most problems with this policy stem from the way it was designed and implemented
z Resistance to new policies--As fund was seen as an imposed programme, managers gave it little support, leading to low
enrolment in the schemes.
z Role of systems actors--Apparently powerless implementers have a high margin of discretion in their personal interactions with clients, allowing them to re-interpret and reshape policies in unexpected ways.
z Ownership is important--As policy implementers are likely to react negatively to new policies formulated without their involvement, use of participatory approaches is necessary to create ownership and engage them in the implementation process
How to think of the anticipated and
unanticipated effects of health policies
All interventions have system-wide effects
Contemporary
system-level
interventions
Pay for performance—traditional approach
Pay for performance-systems thinking
Brainstorming: how did we do it?
How to think of systems-wide effects of
new policies
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Be systematic
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Consider all building blocks
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Consider all important actors
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From the perspective of each actor and each building
block brainstorm on the possible reaction of the system
or its actors to the new policy
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Also consider the consequences of the new policy on
all building blocks
The report
z Available in hard copy in English, French and Spanish
z Available in pdf downloads at:
z http://www.who.int/alliance-hpsr/en/
What questions does the report
address?
9
What is systems thinking?
9
How can we apply it?
9
How can it help us
understand and exploit
synergies for system?
strengthening?
9
What is systems thinking?
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How can we apply it?
9
How can it help us
understand and exploit
synergies for system?
strengthening?
Take home messages
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Policy making needs to take into account the
complexity of systems and the important role,
incentives and power of its stakeholders;
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Several contemporary health systems policies
(particularly in LMICs) need to be reconceptualised
using a systems thinking lens ~ simpler ways of
thinking don’t work
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Systems thinking is a way of thinking, there are tools
that can help in this process but the most first step is
start thinking in a systems respecting way
Selected Systems Thinking tools
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Tools for brainstorming and analyzing
policies
–
Causal Loop Diagram
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To explore non-linear interrelationships
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Systems Dynamics
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To explore consequences of non-linear relationships
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Social Network Analysis
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To map nature of relations between actors
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Concept mapping
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To brainstorm and map the most important effects and
consequences of a policies
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Outcome Mapping
Further reading
z de Savigny D and Adam T. Chapter 2 in: Systems thinking for Health systems strengthening. WHO, 2009.
z Shiell A, Hawe P, Gold L. Complex interventions or complex systems? Implications for health economic evaluation. BMJ. 2008 Jun 7;336(7656):1281-3.
z Leischow SJ, Best A, Trochim WM, Clark PI, Gallagher RS,
Marcus SE and Matthews E. Systems thinking to improve the public's health. Am J Prev Med. 2008 Aug;35(2 Suppl):S196-203.
z Paina L and Peters DH. Understanding pathways for scaling uphealth services through the lens of complex adaptive
systems. Health Policy and Planning 2011;1–9
z Sterman JD. Learning from Evidence in a Complex World. American Journal of Public Health | March 2006, Vol 96, No. 3.
