Systems Thinking for Health Systems …

1 In this latest Flagship Report, the Alliance for Health Policy and Systems Research discusses Systems Thinking a powerful tool for guiding investments in Health Systems . Long used in other disciplines, Systems Thinking works to reveal the underlying characteristics and relationships of Systems . It is a tool that allows key actors from national policy-makers to street-level policy implementers to map and measure their Health system , to identify where some of the key blockages and challenges lie, and to design sound, synergistic and system -ready interventions targeting those weaknesses.

2 With rich, multi-stakeholder partnerships and system -wide optics at its core, Systems Thinking has great yet untapped potential in What is Systems Thinking and how can designing and evaluating system -researchers and policy-makers use it to strengthening interventions. Moving from strengthen Health Systems ?theory to concrete guidance, this Report aims to accelerate a more realistic understanding of How can we use this perspective to better Systems and what makes them change for understand and harness the positive the better. In catalyzing new conceptual effects the synergies among Thinking , this Report illustrates the dynamic interventions to strengthen Health potential and perspective of Systems Thinking Systems ?

3 For achieving Health goals equitably, How can Systems Thinking contribute to sustainably and evaluations of these system -level In this Report, we set out to address the interventions?following broad questions:nnnSystems Thinkingfor Health Systems Strengthening The responses of many Health Systems so far have been generally considered inadequate and na ve.. a system s failure requires a system s solution not a temporary remedy. (WHO World Health Report, 2008).NOVEMBER 2009 Alliance forSystems ResearchHealth Policy andStrengthening Health Systems is a core weigh the need for disease-specific programming with those targeting the Health principle for the World Health Organization, system as a whole; national priorities with member states and the global Health global initiatives; and policy directives with community.

4 While the past few years have street-level realities. Against these seen various developing countries increasing pressures, advancing the principles of equity, their commitment, resources, and universal coverage, and people-centred interventions for strengthening Health approaches only heightens the sheer Systems , there are many competing concepts complexity of the strengthening task. and approaches, but no agreed-upon strengthening formula. As a result, for many As policy-makers and funders increasingly turn Health system stewards and policy-makers in to system -strengthening initiatives, what the developing world, improving a Health really works?

5 And for whom and under what system has become a balancing act. They must circumstances? Systems Thinking demands and creates a Systems Thinking is an approach to problem deeper understanding of the behaviour of solving that views problems as part of a Systems . If a system is always changing, if its wider, dynamic system . Through an increased component parts are always acting, reacting understanding of a system s fundamental and interacting in an often counter-intuitive characteristics, Systems Thinking allows us to process, how can we understand the ways an see with greater precision how Systems work.

6 Intervention might affect it? Systems Thinking The characteristics described below influence works to decode the complexity of a Health especially when taken together how system , then applies this understanding to Systems , including Health Systems , respond to design and evaluate interventions that maximize Health and Health factors or to an ThinkingStrengthening Health SystemsNOVEMBER 20092 Systems Thinking provides a deliberate and Many of the Ten Steps should be familiar to comprehensive suite of tools and approaches any practitioner in Health Systems research or to map, measure and understand the development.

7 In designing the intervention, dynamics of a system , enabling practitioners the first four steps see critical stakeholders to better anticipate how an intervention might including those who will create it, implement affect it. In this Report, we propose Ten Steps it, fund it and be affected by it convene to to Systems Thinking for real-world guidance brainstorm how the intervention might affect in applying the principles of Systems Thinking . the overall system and then to redesign it to We use a major contemporary Health optimize synergies and minimize any financing intervention to demonstrate how a potentially major negative effects.

8 In broad partnership of stakeholders can achieve evaluating the intervention, the remaining six a deeper understanding of the ways an steps walk evaluators and researchers through intervention will affect the Health system . This system -centred decisions around indicators, includes anticipating how the system will methods, design and , what synergies can be harnessed, and what negative emergent behaviour should be controlled. Most Systems , including Health Systems , are:Self-organizing: system dynamics arise spontaneously from internal structureConstantly changing: Systems adjust and readjust at many interactive time scalesTightly linked: the high degree of connectivity means that change in one sub- system affects the othersGoverned by feedback: a positive or negative response that may alter the intervention or its expected effectsNon-linear: relationships within a system cannot be arranged along a simple input-output lineHistory dependent.

9 Short-term effects of intervening may differ from long-term effectsCounter-intuitive: cause and effect are often distant in time and space, defying solutions that pit causes close to the effects they seek to addressResistant to change: seemingly obvious solutions may fail or worsen the Ten Steps to Systems ThinkingNOVEMBER 20093 The Ten Steps to Systems ThinkingIntervention Design1. Convene stakeholders from across the Health system , plus selected intervention designers and implementers, users of the Health system , and representatives of the research Collectively brainstorm on possible system -wide effects of the proposed intervention respecting Systems characteristics and Conceptualize effects to map how the intervention will affect Health and the Health Adapt and redesign to optimize synergies and minimize any negative Design5.

10 Determine indicators that are important to track in the re-designed Choose methods to best track the Select evaluation design that best manages the methods and fits the nature of the Develop a plan and timeline by engaging the necessary Set a budget by considering implications for both the intervention and the evaluation Source funding to support the evaluation before the intervention the Ten Steps, in sequence, opens the redesign a more sophisticated intervention needed space to anticipate the potential that accounts for those potential effects; and effects of an intervention; to conceptualize the to design an evaluation before the actual behaviour of the intervention; to intervention is rolled 20094 Some developing country system stewards evaluating major interventions.