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

Abstract

‘We need new ways of thinking and of working in order to accommodate the complexity of the challenges in and urgent need for health system innovation and change.’ (Herbert and Best 2011) Health systems are complex. Failing to take this complexity into account will continue to hinder efforts to achieve better and more equitable health outcomes. Understanding and working with complexity requires a paradigm shift from linear, reductionist approaches to dynamic and holistic approaches that appreciate the multifaceted and interconnected relationships among health system components, as well as the views, interests and power of its different actors and stakeholders (de Savigny and Adam 2009; Sheikh et al. 2011). Systems thinking helps to re-orient our perspectives by expanding our understanding of the characteristics of complex adaptive systems and identifying how this learning may be applied to system problems and the creation of potential solutions. Long used in other disciplines, systems thinking holds 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 and Peters 2012). Systems thinking is primarily a way of thinking in approaching problems and in designing solutions (Checkland 1985; Cabrera et al. 2008). It is an approach to problem solving that appreciates 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 is critical, and where new policies and actions (of different stakeholders) often generate counterintuitive and unpredictable effects, sometimes long after policies have been implemented (Sterman 2006; de Savigny and Adam 2009). Systems thinking can be applied regardless of the field of enquiry. It is a way to view the world using the general logic underlying the various systems theories (e.g. general systems theory, chaos theory or complexity theory), informed by a wide range of relevant tools and methods (e.g. system dynamics modelling, structured conceptualization, or network analysis), the choice of which will largely depend on the question at hand, the context and available capacity (Best et al. 2007). We interpret systems thinking in the health system context to require us to stand back from a fixation on the individual components (usually the building blocks and their nested sub-systems) and always keep the whole system in mind when designing and evaluating health systems strengthening innovations. This often goes against our classical training in health disciplines (e.g. medicine or epidemiology), which encourages us to understand determinants of health and health system behaviour in reductionist terms rather than to understand system behaviour as driven by relationships among the parts of the system. There is no doubt that classical approaches have made great advances in medicine and public health (e.g. efficacy trials of new medicines or vaccines). The aspired benefits are, however, impeded by the complexity problem, learning failures and implementation challenges (Sterman 2006). This is where systems thinking can complement classical approaches by offering a more holistic perspective to complex problems in complex systems. This requires a radical shift in our approaches and mindsets, combined with mastering different types of skills that are consistent with systems thinking (see Table 1). None of this is unfamiliar to those working in health systems, but what is different in systems thinking is the deliberate, continuous and comprehensive way in which the approach is applied (de Savigny and Adam 2009). Skills of systems thinking Source: Modified from Richmond (2000). Skills of systems thinking Source: Modified from Richmond (2000). Appreciating the complexity and dynamic nature of health systems has increasingly become common language in publications concerned with identifying solutions to improve the population’s health more efficiently and equitably (Sterman 2006; Best et al. 2007; Leischow et al. 2008; Shiell et al. 2008). In 2009, the WHO-based Alliance for Health Policy and Systems Research (HPSR) devoted its third flagship report to this topic, ‘Systems Thinking for Health Systems Strengthening’ (de Savigny and Adam 2009). This report and other recent publications have catalysed an increased interest and demand for moving this kind of ‘thinking’ forward, particularly in how it relates to strengthening health systems in LMICs. This has stemmed from the perceived predominance of mostly theoretical, northern driven experiences using systems thinking principles, and the lack of a wider application of these concepts in health systems and in LMICs. This special issue, co-ordinated by the Alliance for HPSR, is one step towards responding to this demand. It does so by striving to make the shift from abstract concepts and theories to actual experiences and examples of how syst