Constraints to Applying Systems Thinking Concepts in Health Systems: A Regional Perspective from Surveying Stakeholders in Eastern Mediterranean Countries

Document Type: Original Article

Authors

1 Department of Health Management and Policy, American University of Beirut, Beirut, Lebanon

2 Knowledge to Policy (K2P) Center, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon

3 Center for Systematic Reviews of Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon

4 Research, Advocacy and Public Policy-Making, Issam Fares Institute for Public Policy and International Affairs, American University of Beirut, Beirut, Lebanon

5 Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada

6 Alliance for Health Policy and Systems Research, World Health Organization, Geneva, Switzerland

Abstract

Background
Systems Thinking (ST) has recently been promoted as an important approach to health systems strengthening. However, ST is not common practice, particularly in Low- and Middle-Income Countries (LMICs). This paper seeks to explore the barriers that may hinder its application in the Eastern Mediterranean Region (EMR) and possible strategies to mitigate them.
 
Methods
A survey consisting of open-ended questions was conducted with a purposive sample of health policymakers such as senior officials from the Ministry of Health (MoH), researchers, and other stakeholders such as civil society groups and professional associations from ten countries in the region. A total of 62 respondents participated in the study. Thematic analysis was conducted.
 
Results
There was strong recognition of the relevance and usefulness of ST to health systems policy-making and research, although misconceptions about what ST means were also identified. Experience with applying ST was very limited. Approaches to designing health policies in the EMR were perceived as reactive and fragmented (66%). Commonly perceived constraints to application of ST were: a perceived notion of its costliness combined with lack of the necessary funding to operationalize it (53%), competing political interests and lack of government accountability (50%), lack of awareness about relevance and value (47%), limited capacity to apply it (45%), and difficulty in coordinating and managing stakeholders (39%).
 
Conclusion
While several strategies have been proposed to mitigate most of these constraints, they emphasized the importance of political endorsement and adoption of ST at the leadership level, together with building the necessary capacity to apply it and apply the learning in research and practice.

Highlights

Commentaries Published on this Paper

  • Time to Shift from Systems Thinking-Talking to Systems Thinking-Action; Comment on “Constraints to Applying Systems Thinking Concepts in Health Systems: A Regional Perspective from Surveying Stakeholders in Eastern Mediterranean Countries”

            Abstract | PDF

  • “Wood Already Touched by Fire is not Hard to Set Alight”; Comment on “Constraints to Applying Systems Thinking Concepts in Health Systems: A Regional Perspective from Surveying Stakeholders in Eastern Mediterranean Countries”

            Abstract | PDF

  • Application of Systems Thinking in Health: Opportunities for Translating Theory into Practice; Comment on “Constraints to Applying Systems Thinking Concepts in Health Systems: A Regional Perspective from Surveying Stakeholders in Eastern Mediterranean Countries”

            Abstract | PDF

  • Thinking Shift on Health Systems: From Blueprint Health Programmes towards Resilience of Health Systems; Comment on “Constraints to Applying Systems Thinking Concepts in Health Systems: A Regional Perspective from Surveying Stakeholders in Eastern Mediterranean Countries”

            Abstract | PDF

Keywords

Main Subjects


  1. Trochim WM, Cabrera DA, Milstein B, Gallagher RS, Leischow SJ. Practical challenges of systems thinking and modeling in public health. Am J Public Health 2006; 96: 538-46. doi: 10.2105/ajph.2005.066001
  2. Leischow SJ, Best A, Trochim WM, Clark PI, Gallagher RS, Marcus SE, et al. Systems thinking to improve the public's health. Am J Prev Med 2008; 35: S196-203.
  3. Adam T. Advancing the application of systems thinking in health. Health Res Policy Syst 2014; 12: 50. doi: 10.1186/1478-4505-12-50
  4. Jansen MWJ, van Oers HAM, Kok G, de Vries NK. Public health: disconnections between policy, practice and research. Health Res Policy Syst 2010; 8: 37. doi: 10.1186/1478-4505-8-37
  5. de Savigny D, Adam T. Systems thinking for health systems strengthening. Alliance for Health Policy and Systems Research. Geneva: World health Organization:2009.
  6. Swanson RC, Bongiovanni A, Bradley E, Murugan V, Sundewall J, Betigeri A, et al. Toward a consensus on guiding principles for health systems strengthening. PLoS Med 2010; 7: e1000385. doi: 10.1371/journal.pmed.1000385
  7. Chee G, Pielemeier N, Lion A, Connor C. Why differentiating between health system support and health system strengthening is needed. Int J Health Plann Manage 2012; 28: 85-94. doi: 10.1002/hpm.2122
  8. Kamuzora P, Gilson L. Factors influencing implementation of the Community Health Fund in Tanzania. Health Policy Plan 2007; 22: 95-102. doi: 10.1093/heapol/czm001
  9. Agyepong IA, Kodua A, Adjei S, Adam T. 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. Health Policy Plan 2012; 27: iv20-31. doi: 10.1093/heapol/czs083
  10. de Savigny D, Webster J, Agyepong IA, Mwita A, Bart-Plange C, Baffoe-Wilmot A, et al. Introducing vouchers for malaria prevention in Ghana and Tanzania: context and adoption of innovation in health systems. Health Policy Plan 2012; 27: iv32-43. doi: 10.1093/heapol/czs087
  11. Paina L, Peters DH. Understanding pathways for scaling up health services through the lens of complex adaptive systems. Health Policy Plan 2012; 27: 365-73. doi: 10.1093/heapol/czr054
  12. Adam T, Hsu J, de Savigny D, Lavis JN, Røttingen JA, Bennett S. Evaluating health systems strengthening interventions in low-income and middle-income countries: are we asking the right questions? Health Policy Plan 2012; 27: iv9-19. doi: 10.1093/heapol/czs086
  13. World Health Organization (WHO). World Health Report 2000: health systems: improving performance. Geneva: World health Organization; 2000.
  14. Sterman JD. Learning from evidence in a complex world. Am J Public Health 2006; 96: 505-14. doi: 10.2105/AJPH.2005.066043
  15. Holden LM. Complex adaptive systems: concept analysis. J Adv Nurs 2005; 52: 651-7. doi: 10.1111/j.1365-2648.2005.03638.x
  16. Shiell A, Hawe P, Gold L. Complex interventions or complex systems? Implications for health economic evaluation. BMJ 2008; 336: 1281-3. doi: 10.1136/bmj.39569.510521.ad
  17. Atun R. Health systems, systems thinking and innovation. Health Policy Plan 2012; 27: iv4-8. doi: 10.1093/heapol/czs088
  18. Xiao Y, Zhao K, Bishai DM, Peters DH. Essential drugs policy in three rural counties in China: What does a complexity lens add? Soc Sci Med 2012; 93: 220-8. doi: 10.1016/j.socscimed.2012.09.034
  19. World Health Organization Regional Office for the Eastern Mediterranean. The Work of WHO in the Eastern Mediterranean Region Annual Report of the Regional Director. 2013. [cited 2014 October 3]. Available from: http://applications.emro.who.int/docs/RD_annual_Rep_2014_15459_EN.pdf?ua=1
  20. Lavis JN, Hammill AC, Bourgeault IL, Stoddart GL. The supply, distribution and working context of health professionals: Why do things (almost) never change? Ontario Health Promotion E-Bulletin;2007.
  21. El-Jardali F, Lavis JN, Ataya N, Jamal D, Ammar W, Raouf S. Use of health systems evidence by policymakers in eastern Mediterranean countries: views, practices, and contextual influences. BMC Health Serv Res 2012; 12: 200. doi: 10.1186/1472-6963-12-200
  22. El-Jardali F, Lavis JN, Ataya N, Jamal D. Use of health systems and policy research evidence in the health policymaking in eastern Mediterranean countries: views and practices of researchers. Implement Sci 2012; 7: 2. doi: 10.1186/1748-5908-7-2
  23. World Health Organization (WHO). Everybody business: strengthening health systems to improve health outcomes: WHO’s framework for action. Geneva: WHO; 2007.
  24. Wilczynski NL, Haynes RB, Lavis JN, Ramkissoonsingh R, Arnold-Oatley AE. Optimal search strategies for detecting health services research studies in MEDLINE. CMAJ  2004; 171: 1179-85.
  25. Carr EC, Worth A. The use of the telephone interview for research. Nursing Times Research 2001; 6: 511-24. doi: 10.1177/136140960100600107
  26. Sturges JE, Hanrahan KJ. Comparing telephone and face-to-face qualitative interviewing: a research note. Qualitative Research 2004; 4: 107-18. doi: 10.1177/1468794104041110
  27. Hahn EA, Rao D, Cella D, Choi SW.    Comparability of interview- and self-administration of the functional assessment of cancer therapy-general (FACT-G) in English- and Spanish-speaking ambulatory cancer patients. Med Care 2008; 46: 423-31. doi: 10.1097/mlr.0b013e3181648e6e
  28. Fowler FJ, Gallagher PM, Nederend S. Comparing telephone and mail responses to the CAHPS survey instrument. Consumer Assessment of Health Plans Study. Med Care 1999; 37: MS41-9. doi: 10.1097/00005650-199903001-00005
  29. Polit DF, Hungler BP. Nursing research: principles and methods. 4th edition. Philadelphia: Lippincott; 1991.
  30. Kendall J. Axial coding and the grounded theory controversy. West J Nurs Res 1999; 21: 743-57. doi: 10.1177/01939459922044162
  31. Adam T, de Savigny D.  Systems thinking for strengthening health systems in LMICs: need for a paradigm shift. Health Policy Plan 2012;27: iv1-3. doi: 10.1093/heapol/czs084
  32. Bennett S, Agyepong IA, Sheikh K, Hanson K, Ssengooba F, Gilson L. Building the field of health policy and systems research: an agenda for action. PLoS Med 2011; 8: e1001081. doi: 10.1371/journal.pmed.1001081
  33. Adam T, Ahmad S, Bigdeli M, Ghaffar A, Røttingen JA. Trends in Health Policy and Systems Research over the Past Decade: Still Too Little Capacity in Low-Income Countries. PLoS One 2011;6: e27263. doi: 10.1371/journal.pone.0027263
  34. Saleh SS, Alameddine MS, Natafgi NM, Mataria A, Sabri B, Nasher J, et al. The path towards universal health coverage in the Arab uprising countries Tunisia, Egypt, Libya, and Yemen. Lancet 2014; 383: 368-81. doi: 10.1016/s0140-6736(13)62339-9
  35. Kwamie A, van Dijk H, Agyepong IA. Advancing the application of systems thinking in health: realist evaluation of the Leadership Development Programme for district manager decision-making in Ghana. Health Res Policy Syst 2014; 12: 29. doi: 10.1186/1478-4505-12-29
  36. Swanson RC, Cattaneo A, Bradley E, Chunharas S, Atun R, Abbas KM, et al. Rethinking health systems strengthening: key systems thinking tools and strategies for transformational change. Health Policy Plan 2012 27: iv54-61. doi: 10.1093/heapol/czs090
  37. Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet 2010; 376: 1923-58. doi: 10.1016/s0140-6736(10)61854-5
  38. Calhoun JG, Ramiah K, Weist EM, Shortell SM. Development of a core competency model for the Master of Public Health degree. Am J Public Health 2008; 98: 1598-607. doi: 10.2105/ajph.2007.117978
  39. Willis CD, Riley BL, Best A, Ongolo-Zogo P. Strengthening health systems through networks: the need for measurement and feedback. Health Policy Plan 2012; 27: iv62-6. doi: 10.1093/heapol/czs089
  40. Zhang X, Bloom G, Xu X, Chen L, Liang X, Wolcott SJ. Advancing the application of systems thinking in health: managing rural China health system development in complex and dynamic contexts. Health Res Policy Syst 2014;  12: 44. doi: 10.1186/1478-4505-12-44
  41. Sheikh K, Ranson MK, Gilson L. Explorations on people centredness in health systems. Health Policy Plan 2014; 29: ii1-5.  doi: 10.1093/heapol/czu082
  42. Onwuegbuzie AJ, Leech NL. A call for qualitative power analyses. Qual Quant 2007; 41: 105-21. doi: 10.1007/s11135-005-1098-1
  43. Bowling A. Mode of questionnaire administration can have serious effects on data quality. J Public Health (Oxf) 2005; 27: 281-91. doi: 10.1093/pubmed/fdi031
  44. McPake B, Brikci N, Cometto G, Schmidt A, Araujo E. Removing user fees: learning from international experience to support the process. Health Policy Plan 2011; 26: ii104-17. doi: 10.1093/heapol/czr064