Objectives of this session

Transcription

1 Systems thinking for health systems strengthening Taghreed Adam, MD, PhD Alliance for Health Policy and Systems Research, WHO Course in Health systems and policy Master Programme in Public Health Karolinska Institutet, Stockholm, 2 December, 2011

2 Objectives of this session Good understanding of: Main characteristics of complex systems Health systems actors and their role/power What is systems thinking and what are its basic skills Why systems thinking is very important for health systems Initiation in: How to think about the intended and unintended effects of health policies using a systems thinking approach

3 Health systems All organizations, people and action whose primary intent is to promote, restore or maintain health WHO, 2007 Key social goal Improve health by average level of population health health inequities

4 Source: Don de Savigny, Swiss Tropical and Public Health Institute

5 Why renewed interest in health systems? Still enormous disease preventable deaths, particularly in LMICs MDGs deadline approaching but not much progress made Despite massive increase in funding, systems are not delivering fast enough Problems with scaling up essential life saving interventions Why??

6 Source: Don de Savigny, Swiss Tropical and Public Health Institute

7 Health systems are complex! E.g. Architecture of drug supply sub-system in Kenya

8 Foundations

9 System building blocks and values WHO 2007: Everybody's Business. Strengthening health systems to improve health outcomes

10 Underlying health systems framework INPUTS INPUTS & & PROCESSES PROCESSES Governance, Governance, leadership, leadership, regulatory regulatory issues issues Finances Finances Human Human resources resources Infrastructure Infrastructure Procurement Procurement logistics logistics & supplies supplies Information Information OUTPUTS OUTPUTS Strengthened Strengthened system system Improved Improved services services efficiency efficiency access access availability availability affordability affordability acceptability acceptability quality quality safety safety OUTCOMES OUTCOMES Increased Increased coverage coverage utilization utilization responsiveness responsiveness IMPACTS IMPACTS Improved Improved survival survival nutrition nutrition equity equity Reduced Reduced morbidity morbidity impoverishment impoverishment due due to to health health expenditures expenditures OTHER OTHER DETERMINANTS DETERMINANTS OF OF HEALTH HEALTH (Economic, (Economic, Social, Social, Political, Political, Environmental) Environmental) Modified from WHO and HMN

11 Health Systems: More than the building blocks How do we work them together for a more high performance system? Source: Systems thinking for health systems strengthening, 2009

12 So what is systems thinking?

13 Four revolutions There are four revolutions currently underway that will transform health and health systems. These are: Life sciences Information and communication technology Social justice and equity; and Systems thinking to transcend complexity Julio Frenk (2008) Acknowledging the past, Committing to the future.

14 Systems thinking Systems thinking gives deeper insights into: how a system works, why it has problems, how it can be improved Graphic adapted from Ahn A.C. et al. PLoS Med 3: (2006).

15 Characteristics of all complex systems And. nest sub-systems within them but are part of larger systems

16 Example Source: Don de Savigny Swiss Tropical and Public Health Institute

17 focus on events System thinking skills Usual approach Static thinking Systems as effect behaviour as externally driven Tree-by-tree thinking knowledge from understanding details Factors thinking concentrating on factors that influence or correlate Linear thinking view causality running in one direction Source: Systems thinking for health systems strengthening, 2009 Systems thinking approach Dynamic thinking focus on patterns of behaviour Systems as cause responsibility for behaviour from internal actors and rules Forest-thinking knowledge from understanding contexts of relationships Operational thinking concentrating on causality and how behaviour is generated Loop thinking View causality as an on-going process with feedback influencing causes

18 The role and power of systems stakeholders

19 How stakeholder perspectives can vary A health system is. Source: Systems thinking for health systems strengthening, 2009

20 Case study Why there was low enrolment of the voluntary community health insurance scheme in Tanzania? Supposed to cover the rural population (80% of total population) After 10 years, only 10% enrolled were 70% were expected to do so Source: Kamuzora and Gilson. Factors influencing implementation of the Community Health Fund in Tanzania. Health Policy and Planning 2007;22:95 102

21 What was the policy? Payment and benefits: Members pay fixed annual fee per household but no co-payment when using services Households unable to pay the fee are, in principle, entitled to an exemption. Households not joining the CHF pay user fees when attending health facilities. Districts should: manage the fund (monitoring, mobilizing and administering funds, setting exemption policy and targets). ensure quality of care and facility supervision. Sub-district mobilize communities to join, award exemptions and develop community health plans for submission to district.

22 What happened? Interviews with district managers indicated a negative attitude towards exemption; arguments: exemptions are difficult to implement since the number of households qualifying for exemption was large exemption would erode the CHF s financial base exemptions are untenable They all blamed the central government for not addressing the financial sustainability of the CHF They ignored guidelines from the central government requiring them to develop exemption criteria; arguments: it was the responsibility of the village did not have clear exemption criteria It was not their responsibility to set exemption criteria

23 What happened? (2) District managers discouraged exemption proposals coming from the communities; requests were either refused or given no feedback. They considered the policy as an additional separate activity from their routine work like a project imposed on them They did not ensure supervision or availability of drugs and medicines They did not inform people about the exemption policy or the value of joining community health funds People did not see the rationale for joining the fund

24 What have we learnt? Top down versus bottom up policy making most problems with this policy stem from the way it was designed and implemented Resistance to new policies--as fund was seen as an imposed programme, managers gave it little support, leading to low enrolment in the schemes. Role of systems actors--apparently powerless implementers have a high margin of discretion in their personal interactions with clients, allowing them to re-interpret and reshape policies in unexpected ways. Ownership is important--as policy implementers are likely to react negatively to new policies formulated without their involvement, use of participatory approaches is necessary to create ownership and engage them in the implementation process

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26 How to think of the anticipated and unanticipated effects of health policies

27 All interventions have system-wide effects Source: Systems thinking for health systems strengthening, 2009

28 Contemporary system-level interventions

29 Pay for performance traditional approach Source: Systems thinking for health systems strengthening, 2009

30 Pay for performance-systems thinking Source: Systems thinking for health systems strengthening, 2009

31 Brainstorming: how did we do it? Source: Systems thinking for health systems strengthening, 2009

32 How to think of systems-wide effects of new policies Be systematic Consider all building blocks Consider all important actors From the perspective of each actor and each building block brainstorm on the possible reaction of the system or its actors to the new policy Also consider the consequences of the new policy on all building blocks

33 Wrapping up

34 The report Available in hard copy in English, French and Spanish Available in pdf downloads at: Review and feedback welcome by

35 What questions does the report address? What is is systems thinking? How can we apply it? it? How can it it help us us understand and exploit synergies for system? strengthening?

36 Take home messages Policy making needs to take into account the complexity of systems and the important role, incentives and power of its stakeholders; Several contemporary health systems policies (particularly in LMICs) need to be reconceptualised using a systems thinking lens ~ simpler ways of thinking don t work Systems thinking is a way of thinking, there are tools that can help in this process but the most first step is start thinking in a systems respecting way

37 Selected Systems Thinking tools Tools for brainstorming and analyzing policies Causal Loop Diagram To explore non-linear interrelationships Systems Dynamics To explore consequences of non-linear relationships Social Network Analysis To map nature of relations between actors Concept mapping To brainstorm and map the most important effects and consequences of a policies Outcome Mapping To explore how interventions contribute to outcomes

38 Further reading de Savigny D and Adam T. Chapter 2 in: Systems thinking for Health systems strengthening. WHO, Shiell A, Hawe P, Gold L. Complex interventions or complex systems? Implications for health economic evaluation. BMJ Jun 7;336(7656): Leischow SJ, Best A, Trochim WM, Clark PI, Gallagher RS, Marcus SE and Matthews E. Systems thinking to improve the public's health. Am J Prev Med Aug;35(2 Suppl):S Paina L and Peters DH. Understanding pathways for scaling uphealth services through the lens of complex adaptive systems. Health Policy and Planning 2011;1 9 Sterman JD. Learning from Evidence in a Complex World. American Journal of Public Health March 2006, Vol 96, No. 3.

39 Systems thinking video: