Advancing the application of systems thinking in health

Concerted efforts to advance the application of systems thinking in health, particularly in low- and middle-income countries (LMICs) has been advanced by the Alliance for Health Policy and Systems Research. Through the selection of papers reviewed here our aim is to give meaning to abstract concepts and theories through actual applications and experiences of how systems thinking tools and concepts can be used to understand and strengthen health systems, particularly in LMICs

Applying a system dynamics modelling approach to explore policy options for improving neonatal health in Uganda

Description of variables. (DOCX 31 kb

Enhancing the comparability of costing methods: cross-country variability in the prices of non-traded inputs to health programmes

BACKGROUND: National and international policy makers have been increasing their focus on developing strategies to enable poor countries achieve the millennium development goals. This requires information on the costs of different types of health interventions and the resources needed to scale them up, either singly or in combinations. Cost data also guides decisions about the most appropriate mix of interventions in different settings, in view of the increasing, but still limited, resources available to improve health. Many cost and cost-effectiveness studies include only the costs incurred at the point of delivery to beneficiaries, omitting those incurred at other levels of the system such as administration, media, training and overall management. The few studies that have measured them directly suggest that they can sometimes account for a substantial proportion of total costs, so that their omission can result in biased estimates of the resources needed to run a programme or the relative cost-effectiveness of different choices. However, prices of different inputs used in the production of health interventions can vary substantially within a country. Basing cost estimates on a single price observation runs the risk that the results are based on an outlier observation rather than the typical costs of the input. METHODS: We first explore the determinants of the observed variation in the prices of selected "non-traded" intermediate inputs to health programmes – printed matter and media advertising, and water and electricity – accounting for variation within and across countries. We then use the estimated relationship to impute average prices for countries where limited data are available with uncertainty intervals. RESULTS: Prices vary across countries with GDP per capita and a number of determinants of supply and demand. Media and printing were inelastic with respect to GDP per capita, with a positive correlation, while the utilities had a surprisingly negative relationship. All equations had relatively good fits with the data. CONCLUSION: While the preferred option is to derive costs from a random sample of prices in each setting, this option is often not available to analysts. In this case, we suggest that the approach described in this paper could represent a better option than basing policy recommendations on results that are built on the basis of a single, or a few, price observations

When ‘solutions of yesterday become problems of today': crisis-ridden decision making in a complex adaptive system (CAS)—the Additional Duty Hours Allowance in Ghana

Implementation of policies (decisions) in the health sector is sometimes defeated by the system's response to the policy itself. This can lead to counter-intuitive, unanticipated, or more modest effects than expected by those who designed the policy. The health sector fits the characteristics of complex adaptive systems (CAS) and complexity is at the heart of this phenomenon. Anticipating both positive and negative effects of policy decisions, understanding the interests, power and interaction between multiple actors; and planning for the delayed and distal impact of policy decisions are essential for effective decision making in CAS. Failure to appreciate these elements often leads to a series of reductionist approach interventions or ‘fixes'. This in turn can initiate a series of negative feedback loops that further complicates the situation over time. In this paper we use a case study of the Additional Duty Hours Allowance (ADHA) policy in Ghana to illustrate these points. Using causal loop diagrams, we unpack the intended and unintended effects of the policy and how these effects evolved over time. The overall goal is to advance our understanding of decision making in complex adaptive systems; and through this process identify some essential elements in formulating, updating and implementing health policy that can help to improve attainment of desired outcomes and minimize negative unintended effect

Towards a better understanding of the nomenclature used in information-packaging efforts to support evidence-informed policymaking in low- and middle-income countries

Background: The growing recognition of the importance of concisely communicating research evidence and other policy-relevant information to policymakers has underpinned the development of several information-packaging efforts over the past decade. This has led to a wide variability in the types of documents produced, which is at best confusing and at worst discouraging for those they intend to reach. This paper has two main objectives: to develop a better understanding of the range of documents and document names used by the organizations preparing them; and to assess whether there are any consistencies in the characteristics of sampled documents across the names employed to label (in the title) or describe (in the document or website) them. Methods: We undertook a documentary analysis of web-published document series that are prepared by a variety of organizations with the primary intention of providing information to health systems policymakers and stakeholders, and addressing questions related to health policy and health systems with a focus on low- and middle-income countries. No time limit was set. Results: In total, 109 individual documents from 24 series produced by 16 different organizations were included. The name ‘policy brief/briefing’ was the most frequently used (39%) to label or describe a document, and was used in all eight broad content areas that we identified, even though they did not have obviously common traits among them. In terms of document characteristics, most documents (90%) used skimmable formats that are easy to read, with understandable, jargon-free, language (80%). Availability of information on the methods (47%) or the quality of the presented evidence (27%) was less common. One-third (32%) chose the topic based on an explicit process to assess the demand for information from policy makers and even fewer (19%) engaged with policymakers to discuss the content of these documents such as through merit review. Conclusions: This study highlights the need for organizations embarking on future information-packaging efforts to be more thoughtful when deciding how to name these documents and the need for greater transparency in describing their content, purpose and intended audience

Achieving the WHO/UNAIDS antiretroviral treatment 3 by 5 goal: what will it cost?

The "3 by 5" goal to have 3 million people in low and middle income countries on antiretroviral therapy (ART) by the end of 2005 is ambitious. Estimates of the necessary resources are needed to facilitate resource mobilisation and rapid channelling of funds to where they are required. We estimated the financial costs needed to implement treatment protocols, by use of country-specific estimates for 34 countries that account for 90% of the need for ART in resource-poor settings. We first estimated the number of people needing ART and supporting programmes for each country. We then estimated the cost per patient for each programme by country to derive total costs. We estimate that between US5.1 billion dollars and US5.9 billion dollars will be needed by the end of 2005 to provide ART, support programmes, and cover country-level administrative and logistic costs for 3 by 5

Trends in Health Policy and Systems Research over the Past Decade: Still Too Little Capacity in Low-Income Countries

The past decade has seen several high-level events and documents committing to strengthening the field of health policy and systems research (HPSR) as a critical input to strengthening health systems. Specifically, they called for increased production, capacity to undertake and funding for HPSR. The objective of this paper is to assess the extent to which progress has been achieved, an important feedback for stakeholders in this field.Two sources of data have been used. The first is a bibliometric analysis to assess growth in production of HPSR between 2003 and 2009. The six building blocks of the health system were used to define the scope of this search. The second is a survey of 96 research institutions undertaken in 2010 to assess the capacity and funding availability to undertake HPSR, compared with findings from the same survey undertaken in 2000 and 2008. Both analyses focus on HPSR relevant to low-income and middle-income countries (LMICs). Overall, we found an increasing trend of publications on HPSR in LMICs, although only 4% were led by authors from low-income countries (LICs). This is consistent with findings from the institutional survey, where despite improvements in infrastructure of research institutions, a minimal change has been seen in the level of experience of researchers within LIC institutions. Funding availability in LICs has increased notably to institutions in Sub-Saharan Africa; nonetheless, the overall increase has been modest in all regions.Although progress has been made in both the production and funding availability for HPSR, capacity to undertake the research locally has grown at a much slower pace, particularly in LICs where there is most need for this research. A firm commitment to dedicate a proportion of all future funding for research to building capacity may be the only solution to turn the tide

Evaluating health systems strengthening interventions in low-income and middle-income countries: are we asking the right questions?

In recent years, there have been several calls for rigorous health policy and systems research to inform efforts to strengthen health systems (HS) in low- and middle-income countries (LMICs), including the use of systems thinking concepts in designing and evaluating HS strengthening interventions. The objectives of this paper are to assess recent evaluations of HS strengthening interventions to examine the extent to which they ask a broader set of questions, and provide an appropriately comprehensive assessment of the effects of these interventions across the health system. A review of evaluations conducted in 2009-10 was performed to answer these questions. Out of 106 evaluations, less than half (43%) asked broad research questions to allow for a comprehensive assessment of the intervention's effects across multiple HS building blocks. Only half of the evaluations referred to a conceptual framework to guide their impact assessment. Overall, 24% and 9% conducted process and context evaluations, respectively, to answer the question of whether the intervention worked as intended, and if so, for whom, and under what circumstances. Almost half of the evaluations considered HS impact on one building block, while most interventions were complex targeting two or more building blocks. None incorporated evaluation designs that took into account the characteristics of complex adaptive systems such as non-linearity of effects or interactions between the HS building blocks. While we do not argue that all evaluations should be comprehensive, there is a need for more comprehensive evaluations of the wider range of the intervention's effects, when appropriate. Our findings suggest that the full range of barriers to more comprehensive evaluations need to be examined and, where appropriate, addressed. Possible barriers may include limited capacity, lack of funding, inadequate time frames, lack of demand from both researchers and research funders, or difficulties in undertaking this type of evaluatio