The application of systems thinking in health: why use systems thinking?

This paper explores the question of what systems thinking adds to the field of global health. Observing that elements of systems thinking are already common in public health research, the article discusses which of the large body of theories, methods, and tools associated with systems thinking are more useful. The paper reviews the origins of systems thinking, describing a range of the theories, methods, and tools. A common thread is the idea that the behavior of systems is governed by common principles that can be discovered and expressed. They each address problems of complexity, which is a frequent challenge in global health. The different methods and tools are suited to different types of inquiry and involve both qualitative and quantitative techniques. The paper concludes by emphasizing that explicit models used in systems thinking provide new opportunities to understand and continuously test and revise our understanding of the nature of things, including how to intervene to improve people’s health.UKaid; DFI

Rotorcraft aeroelastic stability

Theoretical and experimental developments in the aeroelastic and aeromechanical stability of helicopters and tilt-rotor aircraft are addressed. Included are the underlying nonlinear structural mechanics of slender rotating beams, necessary for accurate modeling of elastic cantilever rotor blades, and the development of dynamic inflow, an unsteady aerodynamic theory for low-frequency aeroelastic stability applications. Analytical treatment of isolated rotor stability in hover and forward flight, coupled rotor-fuselage stability in hover and forward flight, and analysis of tilt-rotor dynamic stability are considered. Results of parametric investigations of system behavior are presented, and correlation between theoretical results and experimental data from small and large scale wind tunnel and flight testing are discussed

Survey of Army/NASA rotorcraft aeroelastic stability research

Theoretical and experimental developments in the aeroelastic and aeromechanical stability of helicopters and tilt-rotor aircraft are addressed. Included are the underlying nonlinear structural mechanics of slender rotating beams, necessary for accurate modeling of elastic cantilever rotor blades, and the development of dynamic inflow, an unsteady aerodynamic theory for low frequency aeroelastic stability applications. Analytical treatment of isolated rotor stability in hover and forward flight, coupled rotor-fuselage stability are considered. Results of parametric investigations of system behavior are presented, and correlations between theoretical results and experimental data from small- and large-scale wind tunnel and flight testing are discussed

Targeting accuracy and impact of a community-identified waiver card scheme for primary care user fees in Afghanistan

<p>Abstract</p> <p>Background</p> <p>User fees are a known common barrier to using health services, particularly among the poor. When fees are present, many facilities have waiver systems for poor patients to exempt them from paying. Targeting waivers to patients who need them most has been a challenge, especially in fragile states, where relevant data are limited and trust in institutions is low.</p> <p>Methods</p> <p>Community-based targeting of vulnerable households was piloted in Afghanistan and evaluated for its feasibility, accuracy and effect on care-seeking. Waiver cards were distributed to very poor and female-headed households in catchment areas of 26 facilities in 10 provinces of Afghanistan in 2005 as one component of a larger health financing study. Households were nominated by community leaders using general guidelines to support 15% of the poorest members. In most cases, waiver cards were pro-actively distributed to them. Targeting accuracy, perceptions, as well the cards' effects on utilization were evaluated in 2007 through household surveys, health facility data, and in-depth interviews and focus group discussions with facility staff and community leaders.</p> <p>Results</p> <p>The waiver system was implemented quickly at all but one facility charging fees. Facility staff and community leaders reported favorable perceptions of implementation and targeting accuracy.</p> <p>However, an analysis of the asset index of beneficiaries indicated that although targeting was progressive, significant leakage and high levels of under-coverage occurred; 42% of cards were used by people in the wealthiest three quintiles, and only 19% of people in the poorest quintile received a card. Households with waiver cards reported higher rates of care-seeking for recent illnesses compared to those without cards (p = 0.02).</p> <p>Conclusions</p> <p>Community identification of beneficiaries is feasible in a fragile state. Several recommendations are discussed to improve targeting accuracy of a waiver card system in the future, in light of this research and other international experiences.</p

Innovation in regulation of rapidly changing health markets

The rapid evolution and spread of health markets across low and middle-income countries (LMICs) has contributed to a significant increase in the availability of health-related goods and services around the world. The support institutions needed to regulate these markets have lagged behind, with regulatory systems that are weak and under-resourced. This paper explores the key issues associated with regulation of health markets in LMICs, and the different goals of regulation, namely quality and safety of care, value for money, social agreement over fair access and financing, and accountability. Licensing, price controls, and other traditional approaches to the regulation of markets for health products and services have played an important role, but they have been of questionable effectiveness in ensuring safety and efficacy at the point of the user in LMICs. The paper proposes a health market systems conceptual framework, using the value chain for the production, distribution and retail of health goods and services, to examine regulation of health markets in the LMIC context. We conclude by exploring the changing context going forwards, laying out implications for future heath market regulation. We argue that the case for new approaches to the regulation of markets for health products and services in LMICs is compelling. Although traditional "command and control" approaches will have a place in the toolkit of regulators, a broader bundle of approaches is needed that is adapted to the national and market-level context of particular LMICs. The implication is that it is not possible to apply standard or single interventions across countries, as approaches proven to work well in one context will not necessarily work well elsewhere.Ukai

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

Evidences of Positive and Negative Transfer Effects Between Highly Similar Perceptual-Motor Tasks

One hundred twenty male undergraduates, each assigned to one of two groups, performed highly similar perceptual-motor tasks varying in difficulty. The tasks were provided by the Multipoint Two-Hand Coordinator. On Day 2, one-half of the Ss in each group changed tasks while one-half continued on the same task. Evidences of positive and negative transfer effects were found with greater positive transfer from the easier to the more difficult task than in the reverse direction. A striking feature of the study was the persistence of negative transfer effects

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