Development of the systems thinking for health actions framework: a literature review and a case study

BACKGROUND: Systems thinking is an approach that views systems with a holistic lens, focusing on how components of systems are interconnected. Specifically, the application of systems thinking has proven to be beneficial when applied to health systems. Although there is plenty of theory surrounding systems thinking, there is a gap between the theoretical use of systems thinking and its actual application to tackle health challenges. This study aimed to create a framework to expose systems thinking characteristics in the design and implementation of actions to improve health. METHODS: A systematised literature review was conducted and a Taxonomy of Systems Thinking Objectives was adapted to develop the new 'Systems Thinking for Health Actions' (STHA) framework. The applicability of the framework was tested using the COVID-19 response in Pakistan as a case study. RESULTS: The framework identifies six key characteristics of systems thinking: (1) recognising and understanding interconnections and system structure, (2) identifying and understanding feedback, (3) identifying leverage points, (4) understanding dynamic behaviour, (5) using mental models to suggest possible solutions to a problem and (6) creating simulation models to test policies. The STHA framework proved beneficial in identifying systems thinking characteristics in the COVID-19 national health response in Pakistan. CONCLUSION: The proposed framework can provide support for those aiming to applying systems thinking while developing and implementing health actions. We also envision this framework as a retrospective tool that can help assess if systems thinking was applied in health actions

A health systems resilience research agenda: moving from concept to practice.

Health system resilience, known as the ability for health systems to absorb, adapt or transform to maintain essential functions when stressed or shocked, has quickly gained popularity following shocks like COVID-19. The concept is relatively new in health policy and systems research and the existing research remains mostly theoretical. Research to date has viewed resilience as an outcome that can be measured through performance outcomes, as an ability of complex adaptive systems that is derived from dynamic behaviour and interactions, or as both. However, there is little congruence on the theory and the existing frameworks have not been widely used, which as diluted the research applications for health system resilience. A global group of health system researchers were convened in March 2021 to discuss and identify priorities for health system resilience research and implementation based on lessons from COVID-19 and other health emergencies. Five research priority areas were identified: (1) measuring and managing systems dynamic performance, (2) the linkages between societal resilience and health system resilience, (3) the effect of governance on the capacity for resilience, (4) creating legitimacy and (5) the influence of the private sector on health system resilience. A key to filling these research gaps will be longitudinal and comparative case studies that use cocreation and coproduction approaches that go beyond researchers to include policy-makers, practitioners and the public

Advancing the science behind human resources for health: highlights from the Health Policy and Systems Research Reader on Human Resources for Health

Health workers are central to people-centred health systems, resilient economies and sustainable development. Given the rising importance of the health workforce, changing human resource for health (HRH) policy and practice and recent health policy and systems research (HPSR) advances, it is critical to reassess and reinvigorate the science behind HRH as part of health systems strengthening and social development more broadly. Building on the recently published Health Policy and Systems Research Reader on Human Resources for Health (the Reader), this commentary reflects on the added value of HPSR underpinning HRH. HPSR does so by strengthening the multi-disciplinary base and rigour of HRH research by (1) valuing diverse research inferences and (2) deepening research enquiry and quality. It also anchors the relevance of HRH research for HRH policy and practice by (3) broadening conceptual boundaries and (4) strengthening policy engagement. Most importantly, HPSR enables us to transform HRH from being faceless numbers or units of health producers to the heart and soul of health systems and vital change agents in our communities and societies. Health workers’ identities and motivation, daily routines and negotiations, and training and working environments are at the centre of successes and failures of health interventions, health system functioning and broader social development. Further, in an increasingly complex globalised economy, the expansion of the health sector as an arena for employment and the liberalisation of labour markets has contributed to the unprecedented movement of health workers, many or most of whom are women, not only between public and private health sectors, but also across borders. Yet, these political, human development and labour market realities are often set aside or elided altogether. Health workers’ lives and livelihoods, their contributions and commitments, and their individual and collective agency are ignored. The science of HRH, offering new discoveries and deeper understanding of how universal health coverage and the Sustainable Development Goals are dependent on millions of health workers globally, has the potential to overcome this outdated and ineffective orthodoxy

The tree under which you sit : district-level management and leadership in maternal and newborn health policy implementation in the Greater Accra Region, Ghana

Health system governance has to do with decision-making – who makes decisions, when, where, how and why. At the district level – the level of care which operationalises health policies – governance is critical, yet remains little understood. Governance has the ability to influence health system performance, and this is essential in maternal and newborn health, where timely decisions are required to support policy implementation. In this regard, district managers are particularly important. They are the link in the middle of the health system, connecting top-end policy formulation to bottom-end implementation. Their abilities to interpret, translate, support and challenge policy will have an effect on what gets operationalised. However, capacity weaknesses in district management and leadership are often cited as a factor in poor health system performance. This thesis seeks to deepen understandings of district-level management, leadership and decision-making for policy and programme management and implementation for maternal and newborn health. Within this, the thesis also seeks to understand the scope for change that an intervention to strengthen management and leadership capacities can bring. This thesis contributes to the applied field of health policy and systems research by drawing on policy implementation theory, organisational management theory and complexity theory as its theoretical basis. A realist approach methodology was undertaken to understand the contexts in which district managers are embedded, how this influences their decision-making, and what the effects of a managerial intervention are, given these contexts. The thesis followed an embedded case study flexible design. The first case study was an exploratory qualitative case study to understand how and why district managers make decisions in maternal and newborn health policy implementation. The second case study was an historical case study of district manager decision-space over time. The third case study was an explanatory qualitative case study of the management and leadership intervention. The final validation of our theorising throughout the cases was achieved through the administration of a questionnaire across all district health management teams of the Great Accra Region. This thesis demonstrates that district managers find themselves in contexts of strong hierarchical authority and resource uncertainty – in particular, lacking financial transparency. This promotes a management and leadership typology which attunes managers towards serving the health system bureaucracy, resulting in reduced district-level responsiveness to maternal and newborn health challenges. The outcome is that district manager decision-space is narrow surrounding resource allocation decisions, and this in turn affects local planning programming and management. The thesis further demonstrates that broader patterns of centralised governmental decision-making have affected the development of the district health system over time. Particularly, the sequencing of decentralisation processes has ensured that national-level decision-making has remained empowered in contrast to district-level decision-making. System fragmentation – through reduced Government of Ghana funds and increasingly verticalised donor funds – has also been a contributor. This accounts for the observed hierarchical authority and resource uncertainty which affects district managers. As a result of these contexts, this thesis also showed that an intervention to strengthen management and leadership capacities was limited in its sustainability. This thesis raises the issues of health system organisation as critical to the potential of district management and leadership effectiveness. It provides evidence that weaknesses in district management and leadership arise out of the organisational governance mismatches in autonomy and responsibility. It suggests that in strengthening management and leadership, approaches which seek to address organisational capacities, not only individual capacities, are needed to convey sustainable change. Advancements in this regard have the scope to improve district manager decision-making for maternal and newborn health policy and programme implementation in the future.</p

Advancing the application of systems thinking in health: realist evaluation of the Leadership Development Programme for district manager decision-making in Ghana

Background Although there is widespread agreement that strong district manager decision-making improves health systems, understanding about how the design and implementation of capacity-strengthening interventions work is limited. The Ghana Health Service has adopted the Leadership Development Programme (LDP) as one intervention to support the development of management and leadership within district teams. This paper seeks to address how and why the LDP ‘works’ when it is introduced into a district health system in Ghana, and whether or not it supports systems thinking in district teams. Methods We undertook a realist evaluation to investigate the outcomes, contexts, and mechanisms of the intervention. Building on two working hypotheses developed from our earlier work, we developed an explanatory case study of one rural district in the Greater Accra Region of Ghana. Data collection included participant observation, document review, and semi-structured interviews with district managers prior to, during, and after the intervention. Working backwards from an in-depth analysis of the context and observed short- and medium-term outcomes, we drew a causal loop diagram to explain interactions between contexts, outcomes, and mechanisms. Results The LDP was a valuable experience for district managers and teams were able to attain short-term outcomes because the novel approach supported teamwork, initiative-building, and improved prioritisation. However, the LDP was not institutionalised in district teams and did not lead to increased systems thinking. This was related to the context of high uncertainty within the district, and hierarchical authority of the system, which triggered the LDP’s underlying goal of organisational control. Conclusions Consideration of organisational context is important when trying to sustain complex interventions, as it seems to influence the gap between short- and medium-term outcomes. More explicit focus on systems thinking principles that enable district managers to better cope with their contexts may strengthen the institutionalisation of the LDP in the future

The path dependence of district manager decision-space in Ghana

The district health system in Ghana today is characterized by high resource-uncertainty and narrow decision-space. This article builds a theory-driven historical case study to describe the influence of path-dependent administrative, fiscal and political decentralization processes on development of the district health system and district manager decision-space. Methods included a non-exhaustive literature review of democratic governance in Ghana, and key informant interviews with high-level health system officials integral to the development of the district health system. Through our analysis we identified four periods of district health system progression: (1) development of the district health system (1970–85); (2) Strengthening District Health Systems Initiative (1986–93); (3) health sector reform planning and creation of the Ghana Health Service (1994–96) and (4) health sector reform implementation (1997–2007). It was observed that district manager decision-space steadily widened during periods (1) and (2), due to increases in managerial profile, and concerted efforts at managerial capacity strengthening. Periods (3) and (4) saw initial augmentation of district health system financing, further widening managerial decision-space. However, the latter half of period 4 witnessed district manager decision-space contraction. Formalization of Ghana Health Service structures influenced by self-reinforcing tendencies towards centralized decision-making, national and donor shifts in health sector financing, and changes in key policy actors all worked to the detriment of the district health system, reversing early gains from bottom-up development of the district health system. Policy feedback mechanisms have been influenced by historical and contemporary sequencing of local government and health sector decentralization. An initial act of administrative decentralization, followed by incomplete political and fiscal decentralization has ensured that the balance of power has remained at national level, with strong vertical accountabilities and dependence of the district on national level. This study demonstrates that the rhetoric of decentralization does not always mirror actual implementation, nor always result in empowered local actors.Resources and well-bein