Adam, Taghreed

de Savigny, Don

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EDITORIALSystems thinking for strengthening healthsystems in LMICs: need for a paradigm shiftTaghreed Adam1* and Don de Savigny21Alliance for Health Policy and Systems Research, World Health Organization, Geneva, Switzerland and 2Swiss Tropical and Public HealthInstitute and University of Basel, Basel, Switzerland*Corresponding author. Alliance for Health Policy and Systems Research, World Health Organization, 1211 Geneva 27, Switzerland.Tel: þ41-22-7913487. E-mail: adamt@who.int.Accepted 17 August 2012Introduction‘We need new ways of thinking and of working in order toaccommodate the complexity of the challenges in and urgent needfor health system innovation and change.’ (Herbert and Best2011)Health systems are complex. Failing to take this complexityinto account will continue to hinder efforts to achieve betterand more equitable health outcomes. Understanding andworking with complexity requires a paradigm shift fromlinear, reductionist approaches to dynamic and holisticapproaches that appreciate the multifaceted and interconnectedrelationships among health system components, as well as theviews, interests and power of its different actors and stake-holders (de Savigny and Adam 2009; Sheikh et al. 2011).Systems thinking helps to re-orient our perspectives byexpanding our understanding of the characteristics of complexadaptive systems and identifying how this learning may beapplied to system problems and the creation of potentialsolutions. Long used in other disciplines, systems thinkingholds great yet largely untapped potential for health systems,particularly in low- and middle-income countries (LMICs)(Senge 1994; Sterman 2006; Shiell et al. 2008; Paina andPeters 2012).Systems thinking is primarily a way of thinking in approachingproblems and in designing solutions (Checkland 1985; Cabreraet al. 2008). It is an approach to problem solving thatappreciates the very nature of complex systems as dynamic,constantly changing, governed by history and by feedback,where the role and influence of stakeholders and context iscritical, and where new policies and actions (of differentstakeholders) often generate counterintuitive and unpredictableeffects, sometimes long after policies have been implemented(Sterman 2006; de Savigny and Adam 2009).Systems thinking can be applied regardless of the field ofenquiry. It is a way to view the world using the general logicunderlying the various systems theories (e.g. general systemstheory, chaos theory or complexity theory), informed by a widerange of relevant tools and methods (e.g. system dynamicsmodelling, structured conceptualization, or network analysis),the choice of which will largely depend on the question athand, the context and available capacity (Best et al. 2007).We interpret systems thinking in the health system context torequire us to stand back from a fixation on the individualcomponents (usually the building blocks and their nestedsub-systems) and always keep the whole system in mind whendesigning and evaluating health systems strengthening innov-ations. This often goes against our classical training in healthdisciplines (e.g. medicine or epidemiology), which encouragesus to understand determinants of health and health systembehaviour in reductionist terms rather than to understandsystem behaviour as driven by relationships among the parts ofthe system. There is no doubt that classical approaches havemade great advances in medicine and public health (e.g.efficacy trials of new medicines or vaccines). The aspiredbenefits are, however, impeded by the complexity problem,learning failures and implementation challenges (Sterman2006). This is where systems thinking can complement classicalapproaches by offering a more holistic perspective to complexproblems in complex systems. This requires a radical shift inour approaches and mindsets, combined with masteringdifferent types of skills that are consistent with systemsthinking (see Table 1). None of this is unfamiliar to thoseworking in health systems, but what is different in sys-tems thinking is the deliberate, continuous and comprehensiveway in which the approach is applied (de Savigny and Adam2009).Appreciating the complexity and dynamic nature of healthsystems has increasingly become common language in publi-cations concerned with identifying solutions to improve thepopulation’s health more efficiently and equitably (Sterman2006; Best et al. 2007; Leischow et al. 2008; Shiell et al. 2008). In2009, the WHO-based Alliance for Health Policy and Systems World Health Organization 2012.All rights reserved. The World Health Organization has granted the Publisher permission for the reproduction of this article.Health Policy and Planning 2012;27:iv1–iv3doi:10.1093/heapol/czs084iv1Research (HPSR) devoted its third flagship report to this topic,‘Systems Thinking for Health Systems Strengthening’ (de Savigny andAdam 2009). This report and other recent publications havecatalysed an increased interest and demand for moving thiskind of ‘thinking’ forward, particularly in how it relates tostrengthening health systems in LMICs. This has stemmed fromthe perceived predominance of mostly theoretical, northerndriven experiences using systems thinking principles, and thelack of a wider application of these concepts in health systemsand in LMICs. This special issue, co-ordinated by the Alliancefor HPSR, is one step towards responding to this demand. Itdoes so by striving to make the shift from abstract concepts andtheories to actual experiences and examples of how systemsthinking can be used to strengthen health systems, particularlyin LMIC settings.This supplement reflects the evolution in our understandingof health systems and how and why public health programmesand policies succeed or fail. It aims to further contribute to thisevolution by encouraging consideration and use of systemsthinking in strengthening health systems and improving healthoutcomes more generally. By sharing recent experiences andideas of ways to institutionalize this kind of thinking, we aimto provoke debate on how we can most effectively incorporatethe complex nature of health systems in designing, implement-ing and evaluating new programmes, policies and strategies.Content of the supplementFirst, the commentary by Atun provides an overview of thefundamental concepts of systems thinking within the healthsystems context, and makes the case for its relevance andprospects for strengthening health systems. It demonstratesthrough examples the lost opportunities for improving thepopulation’s health that could have been mitigated through adeeper and fuller understanding of the dynamic and intercon-nected nature of health systems and their stakeholders.Adam et al. then explore the extent to which recentevaluations of health systems strengthening interventionssought to address a broader set of questions related to thesystem impacts of these interventions, and how thesesystem-wide effects were assessed. This analysis is a followup to an earlier review that found a very limited number ofevaluations considering the system-wide effects of complexhealth interventions.The following two papers by Agyepong et al. and de Savigny et al.present in-depth analyses of the policy processes of two specificinterventions: (1) the additional duty hour allowance in Ghana,and (2) the introduction of vouchers for malaria prevention inGhana and Tanzania. Through a systems thinking lens, thesetwo case studies unveil the elements of success and failure inimplementing the two policies throughout the wholepolicy-making process. They shed light on the role of healthsystems actors, the importance of contextual factors, the valueof anticipating the unintended impact of policies, and system-atically evaluating the implementation process and reacting tothe system’s feedback.These analyses are followed by a methodological paper byPeters et al., which describes how to examine whether a newintervention or policy may develop or distort the healthmarket, a condition called the develop-distort dilemma(DDD). Through three case studies, the authors apply theDDD tool to show how this can be done to ensure thatwell-intentioned interventions are more likely to lead to theexpected health system outcomes while reducing the undesir-able distortions of such efforts.Thereafter, Swanson et al. propose key systems thinkingstrategies and tools that have the potential for transformationalchange in health systems, with three overarching themes thatspan these tools and strategies: collaboration across disciplines,sectors and organizations; on-going, iterative learning; andtransformational leadership. This initial conceptual effort ofwhat it takes to reach transformational change provides astarting point for learning and debate around the need for moreTable 1 Skills of systems thinkingClassical approach Systems thinking approachStatic thinking Dynamic thinkingFocusing on particular events Framing a problem in terms of a pattern of behaviour over timeSystems-as-effect thinking System-as-cause thinkingViewing behaviour generated by a system as driven by external forces Placing responsibility for a behaviour on internal actors who managethe policies and ‘plumbing’ of the systemTree-by-tree thinking Forest thinkingBelieving that really knowing something means focusing on the details Believing that to know something requires understanding the context ofrelationshipsFactors thinking Operational thinkingListing factors that influence or correlate with some result Concentrating on causality and understanding how a behaviour isgeneratedStraight-line thinking Loop thinkingViewing causality as running in one direction, ignoring (either delib-erately or not) the interdependence and interaction between andamong the causesViewing causality as an on-going process, not a one-time event, witheffect feeding back to influence the causes and the causes affectingeach otherSource: Modified from Richmond (2000).iv2 HEALTH POLICY AND PLANNINGsystemic and rigorous perspectives for strengthening healthsystems.Finally, Willis et al. focus on a central element of systemsthinking, the role of relationships. They argue that strengthen-ing of health systems in LMIC settings will be more effective ifwe are able to explicitly and purposefully apply systemsthinking concepts to the design, implementation and evaluationof inter-organizational networks. They go on to argue for theimportance of developing measures of network performance inways that promote learning; and to ensure that the feedbackprocesses to operationalize the use of these measures aredeveloped with and for those who will use these data.Looking forwardWhile there remains a substantial research agenda to informand encourage wider applications of systems thinking inLMICs, the findings presented in this special issue not onlyprovide evidence of the added value of systems thinking instrengthening health systems, but also illustrate the range ofrelevant approaches and strategies that need to be explored oradapted. It shows that conviction alone is not enough—aconcerted effort by all stakeholders at all levels is needed toinstigate a paradigm shift by supporting new initiatives and newways of working that integrate systems thinking in everydaypractice. Only then will health systems make strides inachieving their desired goals, where lessons from past experi-ences are valued and acted upon.Now, with systems thinking becoming increasingly a corecompetency in several MPH and PhD programmes worldwide,the momentum and prospects of integrating systems thinkingin research and policy making are promising. However, signifi-cant challenges remain in converting these concepts andprinciples from the abstract to actual practices, and incontinuing to share and learn from them.We hope that the articles in this special issue are onecontribution to continuing this momentum. The most recentCall for Papers by the Alliance for HPSR and the InternationalDevelopment Research Centre, Canada (IDRC) is another steptowards this, by supporting the development of a newpeer-reviewed journal supplement to be published in 2014,with a specific focus on advancing methodologies, knowledgeand practices for using systems thinking in understanding andstrengthening health systems in LMICs.FundingThe Supplement ‘‘Systems thinking for health systems strengtheningin LMICs: seizing the opportunity’’ gathers studies funded byvarious funders, including, but not limited to, the Alliance forHealth Policy and Systems Research. The Supplement produc-tion was sponsored by the Alliance for Health Policy andSystems Research, World Health Organization. The viewsexpressed in this Editorial are those of the authors and notnecessarily those of the organization they represent.Conflict of interestNone declared.ReferencesBest A, Clark PI, Leischow SJ, Trochim WM. 2007. Greater than the Sum:Systems Thinking in Tobacco Control. Bethesda, MD: National CancerInstitute, US Department of Health and Human Services, NationalInstitutes of Health.Cabrera D, Colosi L, Lobdell C. 2008. Systems thinking. Evaluation andProgram Planning 31: 299–310.Checkland P. 1985. From optimizing to learning – a development ofsystems thinking for the 1990s. Journal of the Operational ResearchSociety 36: 757–67.de Savigny D, Adam T. 2009. Systems Thinking for Health SystemsStrengthening. Geneva: Alliance for Health Policy and SystemsResearch, World Health Organization.Herbert C, Best A. 2011. It’s a matter of values: partnership forinnovative change. Healthcare Papers 2: 31–7.Paina L, Peters DH. 2012. Understanding pathways for scaling up healthservices through the lens of complex adaptive systems. Health Policyand Planning 27: 365–73.Richmond B. 2000. The ‘‘Thinking’’ in Systems Thinking: Seven EssentialSkills. Waltham, MA: Pegasus Communications.Senge PM. 1994. The Fifth Discipline: The Art & Practice of the LearningOrganization. New York: Doubleday Business.Sheikh K, Gilson L, Agyepong IA et al. 2011. Building the field ofhealth policy and systems research: framing the questions. PloSMedicine 8(8).Shiell A, Hawe P, Gold L. 2008. Complex interventions or complexsystems? Implications for health economic evaluation. BritishMedical Journal 336: 1281–3.Sterman JD. 2006. Learning from evidence in a complex world. AmericanJournal of Public Health 96: 505–14.SYSTEMS THINKING FOR HEALTH SYSTEMS IN LMICS iv3

Systems thinking for strengthening health systems in LMICs: need for a paradigm shift

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