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Applied Systems Thinking for Health Systems Research: A Methodological Handbook

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Patient safety in health systems has become more and more important as a theme in health research, and so it is not surprising to see a growing interest in applying systems thinking to healthcare. However there is a difficulty – health systems are very complex and constantly adapting to respond to core drivers and fit needs. How do you apply systems thinking in this situation, and what methods are available? National health authorities, international donors and research practitioners need to know the “how-to” of conducting health systems research from a systems thinking perspective. This book will fill this gap and provide a range of tools that give clear guidance of ways to carry out systems thinking in health, with real-world examples. These methodologies include: • System dynamics and causal loops • Network analysis • Outcome mapping • Soft systems methodology And many more. Written by an international team of experts in health research, this handbook will be essential reading for those working in or researching public health, health policy, health systems, global health, service improvement and innovation in practice.
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... An examination of the methodologies employed in studies reported in Health Policy and Planning (published since 1986) highlights the SD approach, with next to nothing from other systems traditions of work. The 'methodological handbook' edited by de Savigny et al. (2017) may seem to provide an exception to SD partiality. Accounts of 11 methodologies and methods are provided, written by authors with expertise in applying the particular approaches. ...
... A coherent approach to preparing for and responding to health emergencies, using the range of systems methodologies in informed combinations, could not but yield significant benefits. In the final chapter of their 'methodological handbook ', de Savigny et al. (2017) seek to classify the different 'tools' according to the contributions they can make to the sequence of steps in the research process. However, the discussion is superficial and ignores the decades of work that has gone into developing multi-methodological practice in the 'critical systems thinking' tradition of work. ...
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This paper draws lessons from the Ebola Virus Disease epidemic to suggest how health systems research can be strengthened to assist better with preparedness for and mitigation of future public health emergencies. The epidemic killed more than 11 000 people in West Africa between February 2014 and January 2016. The causes of the epidemic and the response to the outbreak harbour many lessons concerning how health systems were overwhelmed and need to be re‐designed in order to cope with future public health emergencies and limit their escalation. From these lessons, it is possible to identify the most significant systemic issues that must be addressed to ensure health systems can exhibit greater resilience in the face of similar events in the future. The paper goes on to consider the current capacity of health systems research (HSR) to assist with the management of these issues and to suggest that critical systems thinking and practice could empower health systems researchers and practitioners in a manner that would give them much greater potency. The research has additional importance now that Covid‐19 has demonstrated that pandemics are not ‘black swan’ events.
... The complexities of researching health care have become recognised in recent years with the emergence of methods specifically designed to capture this, such as rapid ethnography 93 and applied systems thinking. 94 We would therefore recommend using these or similar methods to capture the complexities of the relationships between stakeholders and the environment. ...
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Background When cancer occurs in teenagers and young adults, the impact is far beyond the physical disease and treatment burden. The effect on psychological, social, educational and other normal development can be profound. In addition, outcomes including improvements in survival and participation in clinical trials are poorer than in younger children and older adults with similar cancers. These unique circumstances have driven the development of care models specifically for teenagers and young adults with cancer, often focused on a dedicated purpose-designed patient environments supported by a multidisciplinary team with expertise in the needs of teenagers and young adults. In England, this is commissioned by NHS England and delivered through 13 principal treatment centres. There is a lack of evaluation that identifies the key components of specialist care for teenagers and young adults, and any improvement in outcomes and costs associated with it. Objective To determine whether or not specialist services for teenagers and young adults with cancer add value. Design A series of multiple-methods studies centred on a prospective longitudinal cohort of teenagers and young adults who were newly diagnosed with cancer. Settings Multiple settings, including an international Delphi study of health-care professionals, qualitative observation in specialist services for teenagers and young adults, and NHS trusts. Participants A total of 158 international teenage and young adult experts, 42 health-care professionals from across England, 1143 teenagers and young adults, and 518 caregivers. Main outcome measures The main outcomes were specific to each project: key areas of competence for the Delphi survey; culture of teenagers and young adults care in the case study; and unmet needs from the caregiver survey. The primary outcome for the cohort participants was quality of life and the cost to the NHS and patients in the health economic evaluation. Data sources Multiple sources were used, including responses from health-care professionals through a Delphi survey and face-to-face interviews, interview data from teenagers and young adults, the BRIGHTLIGHT survey to collect patient-reported data, patient-completed cost records, hospital clinical records, routinely collected NHS data and responses from primary caregivers. Results Competencies associated with specialist care for teenagers and young adults were identified from a Delphi study. The key to developing a culture of teenage and young adult care was time and commitment. An exposure variable, the teenagers and young adults Cancer Specialism Scale, was derived, allowing categorisation of patients to three groups, which were defined by the time spent in a principal treatment centre: SOME (some care in a principal treatment centre for teenagers and young adults, and the rest of their care in either a children’s or an adult cancer unit), ALL (all care in a principal treatment centre for teenagers and young adults) or NONE (no care in a principal treatment centre for teenagers and young adults). The cohort study showed that the NONE group was associated with superior quality of life, survival and health status from 6 months to 3 years after diagnosis. The ALL group was associated with faster rates of quality-of-life improvement from 6 months to 3 years after diagnosis. The SOME group was associated with poorer quality of life and slower improvement in quality of life over time. Economic analysis revealed that NHS costs and travel costs were similar between the NONE and ALL groups. The ALL group had greater out-of-pocket expenses, and the SOME group was associated with greater NHS costs and greater expense for patients. However, if caregivers had access to a principal treatment centre for teenagers and young adults (i.e. in the ALL or SOME groups), then they had fewer unmet support and information needs. Limitations Our definition of exposure to specialist care using Hospital Episode Statistics-determined time spent in hospital was insufficient to capture the detail of episodes or account for the variation in specialist services. Quality of life was measured first at 6 months, but an earlier measure may have shown different baselines. Conclusions We could not determine the added value of specialist cancer care for teenagers and young adults as defined using the teenage and young adult Cancer Specialism Scale and using quality of life as a primary end point. A group of patients (i.e. those defined as the SOME group) appeared to be less advantaged across a range of outcomes. There was variation in the extent to which principal treatment centres for teenagers and young adults were established, and the case study indicated that the culture of teenagers and young adults care required time to develop and embed. It will therefore be important to establish whether or not the evolution in services since 2012–14, when the cohort was recruited, improves quality of life and other patient-reported and clinical outcomes. Future work A determination of whether or not the SOME group has similar or improved quality of life and other patient-reported and clinical outcomes in current teenage and young adult service delivery is essential if principal treatment centres for teenagers and young adults are being commissioned to provide ‘joint care’ models with other providers. Funding This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research ; Vol. 9, No. 12. See the NIHR Journals Library website for further project information.
... 6 Although research methodologies are recognised, applied research on how resilience is created or strengthened in health systems-a crucial step to developing strategies to promote resilience-remains limited. 7 As we have seen with COVID-19, strong debates continue around the most Summary box ► Improving resilience could help health system responses to shocks like COVID-19, but the research has so far remained primarily theoretical. In order to develop and implement strategies to strengthen systems, we need to conduct applied research towards a cohesive set of goals. ...
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Health system resilience, known as the ability for health systems to absorb, adapt or transform to maintain essential functions when stressed or shocked, has quickly gained popularity following shocks like COVID-19. The concept is relatively new in health policy and systems research and the existing research remains mostly theoretical. Research to date has viewed resilience as an outcome that can be measured through performance outcomes, as an ability of complex adaptive systems that is derived from dynamic behaviour and interactions, or as both. However, there is little congruence on the theory and the existing frameworks have not been widely used, which as diluted the research applications for health system resilience. A global group of health system researchers were convened in March 2021 to discuss and identify priorities for health system resilience research and implementation based on lessons from COVID-19 and other health emergencies. Five research priority areas were identified: (1) measuring and managing systems dynamic performance, (2) the linkages between societal resilience and health system resilience, (3) the effect of governance on the capacity for resilience, (4) creating legitimacy and (5) the influence of the private sector on health system resilience. A key to filling these research gaps will be longitudinal and comparative case studies that use cocreation and coproduction approaches that go beyond researchers to include policy-makers, practitioners and the public.
... 6 Although research methodologies are recognised, applied research on how resilience is created or strengthened in health systems-a crucial step to developing strategies to promote resilience-remains limited. 7 As we have seen with COVID-19, strong debates continue around the most Summary box ► Improving resilience could help health system responses to shocks like COVID-19, but the research has so far remained primarily theoretical. In order to develop and implement strategies to strengthen systems, we need to conduct applied research towards a cohesive set of goals. ...
Article
Full-text available
Health system resilience, known as the ability for health systems to absorb, adapt or transform to maintain essential functions when stressed or shocked, has quickly gained popularity following shocks like COVID-19. The concept is relatively new in health policy and systems research and the existing research remains mostly theoretical. Research to date has viewed resilience as an outcome that can be measured through performance outcomes, as an ability of complex adaptive systems that is derived from dynamic behaviour and interactions, or as both. However, there is little congruence on the theory and the existing frameworks have not been widely used, which as diluted the research applications for health system resilience. A global group of health system researchers were convened in March 2021 to discuss and identify priorities for health system resilience research and implementation based on lessons from COVID-19 and other health emergencies. Five research priority areas were identified: (1) measuring and managing systems dynamic performance, (2) the linkages between societal resilience and health system resilience, (3) the effect of governance on the capacity for resilience, (4) creating legitimacy and (5) the influence of the private sector on health system resilience. A key to filling these research gaps will be longitudinal and comparative case studies that use cocreation and coproduction approaches that go beyond researchers to include policy-makers, practitioners and the public.
... CLDs are not a suitable choice for testing and modelling potential solutions to problems. Instead, system dynamics models, which often utilise CLDs in their development, are a better fit for this research need (de Savigny et al., 2017). ...
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Payment for performance (P4P) has been employed in low and middle-income (LMIC) countries to improve quality and coverage of maternal and child health (MCH) services. However, there is a lack of consensus on how P4P affects health systems. There is a need to evaluate P4P effects on health systems using methods suitable for evaluating complex systems. We developed a causal loop diagram (CLD) to further understand the pathways to impact of P4P on delivery and uptake of MCH services in Tanzania. The CLD was developed and validated using qualitative data from a process evaluation of a P4P scheme in Tanzania, with additional stakeholder dialogue sought to strengthen confidence in the diagram. The CLD maps the interacting mechanisms involved in provider achievement of targets, reporting of health information, and population care seeking, and identifies those mechanisms affected by P4P. For example, the availability of drugs and medical commodities impacts not only provider achievement of P4P targets but also demand of services and is impacted by P4P through the availability of additional facility resources and the incentivisation of district managers to reduce drug stock outs. The CLD also identifies mechanisms key to facility achievement of targets but are not within the scope of the programme; the activities of health facility governing committees and community health workers, for example, are key to demand stimulation and effective resource use at the facility level but both groups were omitted from the incentive system. P4P design considerations generated from this work include appropriately incentivising the availability of drugs and staffing in facilities and those responsible for demand creation in communities. Further research using CLDs to study heath systems in LMIC is urgently needed to further our understanding of how systems respond to interventions and how to strengthen systems to deliver better coverage and quality of care.
... Different design options will be costed to enable consideration of sustainability and scale-up at this early stage. We will also work closely with Ghana Health Service and the CHPS programme, taking an embedded research approach 53 to ensure that issues of sustainability and scale-up are central to the design. ...
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Introduction With rapid urbanisation in low-income and middle-income countries, health systems are struggling to meet the needs of their growing populations. Community-based Health Planning and Services (CHPS) in Ghana have been effective in improving maternal and child health in rural areas; however, implementation in urban areas has proven challenging. This study aims to engage key stakeholders in urban communities to understand how the CHPS model can be adapted to reach poor urban communities. Methods and analysis A Participatory Action Research (PAR) will be used to develop an urban CHPS model with stakeholders in three selected CHPS zones: (a) Old Fadama (Yam and Onion Market community), (b) Adedenkpo and (c) Adotrom 2, representing three categories of poor urban neighbourhoods in Accra, Ghana. Two phases will be implemented: phase 1 (‘reconnaissance phase) will engage and establish PAR research groups in the selected zones, conduct focus groups and individual interviews with urban residents, households vulnerable to ill-health and CHPS staff and key stakeholders. A desk review of preceding efforts to implement CHPS will be conducted to understand what worked (or not), how and why. Findings from phase 1 will be used to inform and co-create an urban CHPS model in phase 2, where PAR groups will be involved in multiple recurrent stages (cycles) of community-based planning, observation, action and reflection to develop and refine the urban CHPS model. Data will be managed using NVivo software and coded using the domains of community engagement as a framework to understand community assets and potential for engagement. Ethics and dissemination This study has been approved by the University of York’s Health Sciences Research Governance Committee and the Ghana Health Service Ethics Review Committee. The results of this study will guide the scale-up of CHPS across urban areas in Ghana, which will be disseminated through journal publications, community and government stakeholder workshops, policy briefs and social media content. This study is also funded by the Medical Research Council, UK.
... However, nearly half of these peer-reviewed articles have been calls for more systems thinking approaches, with fewer empirical examples of applied systems thinking (Carey et al., 2015). Despite the important body of knowledge that has formed through the articulation of systems thinking frameworks (Adam and De Savigny, 2012), collection of case studies (Adam, 2014), and explanations of tools and methods (De Savigny et al., 2017), systems thinking in practice, particularly in low-and middle-income countries (LMICs), has remained broadly overlooked as a means of addressing health system challenges. The COVID-19 pandemic has only underscored the systemic difficulties that arise when health actions are considered in discrete and shortterm fashion, linkages to broader social systems are not fully considered and potential consequences are not holistically thought through. ...
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While systems thinking has been generally acknowledged as important to the field of health policy and systems research (HPSR), it remains underutilized. In particular, systems thinking has been perceived as predominantly conceptual, with fewer applications of systems thinking documented. This commentary makes three key points, namely that (1) advances in applied systems thinking in HPSR have been hindered by an imprecision in terminology, conflating ‘[health] systems approaches’ with complex adaptive systems theory; (2) limited examples of applied systems thinking have been highlighted and recognized in research, but have not been fully and equally appreciated in policymaking and practice and (3) explicit use of theory, long-term research-policy collaborations and better documentation of evidence can increase the use and usefulness of applied systems thinking in HPSR. By addressing these matters, the potentials of systems thinking in HPSR can be truly unlocked.
... 6 Nowadays, a broad landscape of approaches focuses specifically on behaviour and mechanisms that emerge from interactions between involved actors and the environment. [7][8][9] Often based on some form of complexity theory, these approaches work from the assumption that change does not take place in isolation and that interaction and inter-relatedness are central concepts to study. In light of COVID-19, it is again clear that intervention and context are inseparable and that randomised controlled trials (RCTs) cannot address everything we need to know. 10 The body of knowledge on complexity and systems approaches to health and health innovations is growing. ...
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Medical technologies, e-health and personalised medicine are rapidly changing the healthcare landscape. Successful implementation depends on interactions between the technology, the actors and the context. More traditional reductionistic approaches aim to understand isolated factors and linear cause–effect relations and have difficulties in addressing inter-relatedness and interaction. Complexity theory offers a myriad of approaches that focus specifically on behaviour and mechanisms that emerge from interactions between involved actors and the environment. These approaches work from the assumption that change does not take place in isolation and that interaction and inter-relatedness are central concepts to study. However, developments are proceeding fast and along different lines. This can easily lead to confusion about differences and usefulness in clinical and healthcare research and practice. Next to this, reductionistic and complexity approaches have their own merits and much is to be gained from using both approaches complementary. To this end, we propose three lines in complexity research related to health innovation and discuss ways in which complexity approaches and reductionistic approaches can act compatibly and thereby strengthen research designs for developing, implementing and evaluating health innovations.
Chapter
Health systems are fluid and their components are interdependent in complex ways. Policymakers, academics and students continually endeavour to understand how to manage health systems to improve the health of populations. However, previous scholarship has often failed to engage with the intersections and interactions of health with a multitude of other systems and determinants. This book ambitiously takes on the challenge of presenting health systems as a coherent whole, by applying a systems-thinking lens. It focuses on Malaysia as a case study to demonstrate the evolution of a health system from a low-income developing status to one of the most resilient health systems today. A rich collaboration of multidisciplinary academics working with policymakers who were at the coalface of decision-making and practitioners with decades of experience, provides a candid analysis of what worked and what did not. The result is an engaging, informative and thought-provoking intervention in the debate. This title is Open Access.
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Background The large burden of injuries falls disproportionately on low/middle-income countries (LMICs). Health system interventions improve outcomes in high-income countries. Assessing LMIC trauma systems supports their improvement. Evaluating systems using a Three Delays framework, considering barriers to seeking (Delay 1), reaching (Delay 2) and receiving care (Delay 3), has aided maternal health gains. Rapid assessments allow timely appraisal within resource and logistically constrained settings. We systematically reviewed existing literature on the assessment of LMIC trauma systems, applying the Three Delays framework and rapid assessment principles. Methods We conducted a systematic review and narrative synthesis of articles assessing LMIC trauma systems. We searched seven databases and grey literature for studies and reports published until October 2018. Inclusion criteria were an injury care focus and assessment of at least one defined system aspect. We mapped each study to the Three Delays framework and judged its suitability for rapid assessment. Results Of 14 677 articles identified, 111 studies and 8 documents were included. Sub-Saharan Africa was the most commonly included region (44.1%). Delay 3, either alone or in combination, was most commonly assessed (79.3%) followed by Delay 2 (46.8%) and Delay 1 (10.8%). Facility assessment was the most common method of assessment (36.0%). Only 2.7% of studies assessed all Three Delays. We judged 62.6% of study methodologies potentially suitable for rapid assessment. Conclusions Whole health system injury research is needed as facility capacity assessments dominate. Future studies should consider novel or combined methods to study Delays 1 and 2, alongside care processes and outcomes.
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