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

Antiretroviral treatment roll-out in a resource-constrained setting: capitalizing on nursing resources in Botswana

PROBLEM: As programmes to deliver antiretroviral therapy (ART) are implemented in resource-constrained settings, the problem becomes not how these programmes are going to be financed but who will be responsible for delivering and sustaining them. APPROACH: Physician-led models of HIV treatment and care that have evolved in industrialized countries are not replicable in settings with a high prevalence of HIV infection and limited access to medical staff. Therefore, models of care need to make better use of available human resources. LOCAL SETTING: Using Botswana as an example, we discuss how nurses are underutilized in long-term clinical management of patients requiring ART. RELEVANT CHANGES: We argue that for ART-delivery programmes to be sustainable, nurses will need to provide a level of clinical care for patients receiving this therapy, including prescribing ART and managing common adverse effects. LESSONS LEARNED: Practicalities involved in scaling up nurse-led models of ART delivery include overcoming political and professional barriers, identifying educational requirements, agreeing on the limitations of nursing practice, developing clear referral pathways between medical and nursing personnel, and developing mechanisms to monitor and supervise practice. Operational research is required to demonstrate that such models are safe, effective and sustainable

Survey of HIV mothers in Botswana: Feeding methods, support, status disclosure and infant testing

A survey of HIV positive mothers in Botswana, Africa, all enrolled in a PMTCT programme, was conducted. A total of 305 mothers from randomly selected sites volunteered and completed the survey related to infant feeding, disclosure of HIV status, infant testing, and support from family and clinic services. The majority of mothers used formula feeding (64%) with their infants and almost half of the mothers indicated that they believed breastfeeding to be unsafe. The majority of mothers reported having disclosed their HIV status to partners and family and felt they had benefited from having done so. Social stigma did not appear to be a significant concern for the mothers in this study. Overall, mothers were very positive concerning the support they received from partners, family, and medical/clinic services. HIV testing was reported for 178 babies with 5 (3%) found to be positive for HIV. A discussion of the findings, along with recommendations for areas needing further study and attention, is provided