Applying systems thinking to strengthen health systems

Systems thinking represents a unique theoretical and practical contribution. It facilitates ways to cross disciplines, and brings previously unused tools and approaches to tackle global health implementation differently. Future Health Systems (FHS) has played a major role in applying and advocating for the approach as a means to holistically understand health systems in low- and middle-income countries, as well as adaptation and scale-up of the project’s interventions

How Learning-by-Doing Can Help Cut Through Complexity in Health Service Delivery

There is no single solution for successfully scaling-up key interventions and reaching the poor. Implementation research, using tools and approaches that are inclusive, participatory, and flexible, is essential for “learning-by-doing” to understand what works best in a particular context. Throughout the duration of the Future Health Systems project (FHS), country teams have committed to undertaking systematic learning though implementation research and by bringing together key actors involved in service delivery. In this Key Message Brief, we share some examples of how FHS teams have embodied a “learning-by-doing” approach, and what the consequences of this approach have been.UK Ai

Expecting the unexpected: applying the Develop-Distort Dilemma to maximize positive market impacts in health

Although health interventions start with good intentions to develop services for disadvantaged populations, they often distort the health market, making the delivery or financing of services difficult once the intervention is over: a condition called the ‘Develop-Distort Dilemma’ (DDD). In this paper, we describe how to examine whether a proposed intervention may develop or distort the health market. Our goal is to produce a tool that facilitates meaningful and systematic dialogue for practitioners and researchers to ensure that well-intentioned health interventions lead to productive health systems while reducing the undesirable distortions of such efforts. We apply the DDD tool to plan for development rather than distortions in health markets, using intervention research being conducted under the Future Health Systems consortium in Bangladesh, China and Uganda. Through a review of research proposals and interviews with principal investigators, we use the DDD tool to systematically understand how a project fits within the broader health market system, and to identify gaps in planning for sustainability. We found that while current stakeholders and funding sources for activities were easily identified, future ones were not. The implication is that the projects could raise community expectations that future services will be available and paid for, despite this actually being uncertain. Each project addressed the ‘rules’ of the health market system differently. The China research assesses changes in the formal financing rules, whereas Bangladesh and Uganda’s projects involve influencing community level providers, where informal rules are more important. In each case, we recognize the importance of building trust between providers, communities and government officials. Each project could both develop and distort local health markets. Anyone intervening in the health market must recognize the main market perturbations, whether positive or negative, and manage them so as to maximize the benefits to the health system and population health.UKai

DUAL PRACTICE IN KAMPALA, UGANDA: A MIXED METHODS STUDY OF MANAGEMENT AND POLICY

Problem Statement: Dual practice is widespread in developing countries and frequently sparks discussions about its effects on service delivery and system performance. In the absence of empirical studies, policy-makers often rely on anecdotal evidence for policy discussions and planning. This thesis examines dual practice in Kampala, Uganda, where, anecdotally, almost all government health workers have dual practice. Methods: An exploratory mixed methods design included multiple case studies of government facilities with embedded units of analysis, as well as a self-administered survey containing preference elicitation and demographic questions completed by government doctors and nurses. Manuscript 1 uses interview and survey data to develop a framework for understanding dual practice. Manuscript 2 uses qualitative data and develops a causal loop diagram to describe the interactions, adaptations, and management practices related to dual practice. Manuscripts 3 and 4 use best-worst scaling to identify and elicit provider preferences on the consequences of dual practice and on dual potential practice policy options, respectively. Results: Manuscript 1 describes the heterogeneous nature of dual practice in Uganda. Manuscript 2 illustrates the historical development of dual practice in Uganda and explains informal management practices within government facilities. Manuscript3 produces a ranking of providers’ perceptions of dual practice consequences. Manuscript 4 identifies policy options linked to salary, dual practice policy, work structure, and benefits. Policy options related to salary and work structure were most important to health providers. Dual practice policy options were least important. Conclusions: This study underscores the importance of defining dual practice locally and accounting for differences between doctors and nurses and among doctors. A formal policy on dual practice should carefully consider unintended feedback in the system, the role of public and private incentives for government providers, and the costs and benefits of various policy options. Provider stated preferences point to potential policies to improve health workforce management in the short term – such as supportive supervision, while resources are secured for longer-term policies – salary increases, civil service reform. Future research should consider evaluating the effects of dual practice on service delivery and the effectiveness of policy initiatives

Advancing the application of systems thinking in health: why cure crowds out prevention

INTRODUCTION: This paper presents a system dynamics computer simulation model to illustrate unintended consequences of apparently rational allocations to curative and preventive services. METHODS: A modeled population is subject to only two diseases. Disease A is a curable disease that can be shortened by curative care. Disease B is an instantly fatal but preventable disease. Curative care workers are financed by public spending and private fees to cure disease A. Non-personal, preventive services are delivered by public health workers supported solely by public spending to prevent disease B. Each type of worker tries to tilt the balance of government spending towards their interests. Their influence on the government is proportional to their accumulated revenue. RESULTS: The model demonstrates effects on lost disability-adjusted life years and costs over the course of several epidemics of each disease. Policy interventions are tested including: i) an outside donor rationally donates extra money to each type of disease precisely in proportion to the size of epidemics of each disease; ii) lobbying is eliminated; iii) fees for personal health services are eliminated; iv) the government continually rebalances the funding for prevention by ring-fencing it to protect it from lobbying. The model exhibits a “spend more get less” equilibrium in which higher revenue by the curative sector is used to influence government allocations away from prevention towards cure. Spending more on curing disease A leads paradoxically to a higher overall disease burden of unprevented cases of disease B. This paradoxical behavior of the model can be stopped by eliminating lobbying, eliminating fees for curative services, and ring-fencing public health funding. CONCLUSIONS: We have created an artificial system as a laboratory to gain insights about the trade-offs between curative and preventive health allocations, and the effect of indicative policy interventions. The underlying dynamics of this artificial system resemble features of modern health systems where a self-perpetuating industry has grown up around disease-specific curative programs like HIV/AIDS or malaria. The model shows how the growth of curative care services can crowd both fiscal and policy space for the practice of population level prevention work, requiring dramatic interventions to overcome these trends.DFI

Advancing the application of systems thinking in health: understanding the growing complexity governing immunization services in Kerala, India

The study calls for greater consideration of dynamics of vaccine acceptability while formulating immunization policies and program strategies. Governing immunization services in a way that achieves and maintains desired population coverage levels is complex, as it involves interactions of multiple actors and contexts. A complex adaptive system lens helped to uncover the ‘real’ drivers for change in an immunization program experiencing declining coverage in northern districts of Kerala. The analytical approaches adopted in this study are not only applicable to immunization or Kerala but to all complex interventions, health systems problems, and contexts

Advancing the application of systems thinking in health: exploring dual practice and its management in Kampala, Uganda

Many full-time Ugandan government health providers take on additional jobs; this dual practice prevails because public and private sector incentives, non-financial and financial, are complementary. Understanding how dual practice evolves and how it is managed locally is essential for health workforce policy, planning, and performance discussions in Uganda and similar settings. Available literature examines dual practice rather narrowly and generally only from the perspective of physicians. In this study we describe the complex patterns that characterize the evolution of dual practice in Uganda, and the local management practices that emerged in response, in five government facilities

SDG5 “Gender Equality” and the COVID-19 pandemic: A rapid assessment of health system responses in selected upper-middle and high-income countries

Introduction: The COVID-19 pandemic disrupted healthcare and societies, exacerbating existing inequalities for women and girls across every sphere. Our study explores health system responses to gender equality goals during the COVID-19 pandemic and inclusion in future policies. Methods: We apply a qualitative comparative approach, drawing on secondary sources and expert information; the data was collected from March–July 2022. Australia, Brazil, Germany, the United Kingdom, and the USA were selected, reflecting upper-middle and high-income countries with established public health and gender policies but different types of healthcare systems and epidemiological and geo-political conditions. Three sub-goals of SDG5 were analyzed: maternity care/reproductive health, gender-based violence, and gender equality/women's leadership. Results: We found similar trends across countries. Pandemic policies strongly cut into women's health, constrained prevention and support services, and weakened reproductive rights, while essential maternity care services were kept open. Intersecting gender inequalities were reinforced, sexual violence increased and women's leadership was weak. All healthcare systems failed to protect women's health and essential public health targets. Yet there were relevant differences in the responses to increased violence and reproductive rights, ranging from some support measures in Australia to an abortion ban in the US. Conclusions: Our study highlights a need for revising pandemic policies through a feminist lens

Situational analysis of teaching and learning of medicine and nursing students at Makerere University College of Health Sciences

<p>Abstract</p> <p>Background</p> <p>Makerere University College of Health Sciences (MakCHS) in Uganda is undergoing a major reform to become a more influential force in society. It is important that its medicine and nursing graduates are equipped to best address the priority health needs of the Ugandan population, as outlined in the government’s Health Sector Strategic Plan (HSSP). The assessment identifies critical gaps in the core competencies of the MakCHS medicine and nursing and ways to overcome them in order to achieve HSSP goals.</p> <p>Methods</p> <p>Documents from the Uganda Ministry of Health were reviewed, and medicine and nursing curricula were analyzed. Nineteen key informant interviews (KII) and seven focus group discussions (FGD) with stakeholders were conducted. The data were manually analyzed for emerging themes and sub-themes. The study team subsequently used the checklists to create matrices summarizing the findings from the KIIs, FGDs, and curricula analysis. Validation of findings was done by triangulating information from the different data collection methods.</p> <p>Results</p> <p>The core competencies that medicine and nursing students are expected to achieve by the end of their education were outlined for both programs. The curricula are in the process of reform towards competency-based education, and on the surface, are well aligned with the strategic needs of the country. But implementation is inadequate, and can be changed:</p> <p>• Learning objectives need to be more applicable to achieving competencies.</p> <p>• Learning experiences need to be more relevant for competencies and setting in which students will work after graduation (i.e. not just clinical care in a tertiary care facility).</p> <p>• Student evaluation needs to be better designed for assessing these competencies.</p> <p>Conclusion</p> <p>MakCHS has made a significant attempt to produce relevant, competent nursing and medicine graduates to meet the community needs. Ways to make them more effective though deliberate efforts to apply a competency-based education are possible.</p