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Systems Thinking for District Health Systems: Applications, Issues and Challenges
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Systems Thinking for District Health Systems: Applications, Issues and Challenges

A special issue of Systems (ISSN 2079-8954). This special issue belongs to the section "Systems Practice in Social Science".

Deadline for manuscript submissions: closed (31 January 2024) | Viewed by 15935

Special Issue Editors

Prof. Dr. Don De Savigny

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Guest Editor
Swiss Tropical and Public Health Institute, 4123 Allschwil, Switzerland
Interests: global public health; health systems; health policies; systems thinking; health informatics
Dr. Ntuli Angyelile Kapologwe

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Guest Editor
Director of Health, Social Welfare & Nutrition Services, President's Office for Regional Administration and Local Government, P.O. Box 1923, Dodoma, Tanzania
Interests: national and sub-national health systems; primary health care; systems thinking; community health; governance; management

Special Issue Information

Dear Colleagues,

There is an unprecedented increase in the application of systems thinking to the many ongoing and emerging health system challenges we face at present.  An arsenal of systems thinking approaches and methods is now being applied (Thelen et al. 2023). Applications are typical at global and national policy levels, as well as at institutional levels. However, more recently, subnational district health systems in low- and middle-income countries (LMICs) are applying systems thinking with the potential to improve health outcomes and advance overall health system performance significantly. This Special Issue seeks scientific contributions that examine the practical implementation of systems thinking in district health systems, as well as those that critically reflect on its limitations and potential for improving health outcomes in low- and middle-income countries. Potential topics of interest include, but are not limited to:

  • The use of systems thinking in improving the coordination and integration of health services at the district level.
  • The application of systems thinking in addressing health inequities and social determinants of health within district health systems.
  • The role of community engagement and participation in adopting a systems approach to health system strengthening.
  • The use of systems thinking in improving the performance and resilience of district health systems in the face of crises and emergencies.
  • The application of systems thinking in the design and implementation of system-level interventions.
  • The use of systems thinking to evaluate system effectiveness and effective coverage.
  • The practice of systems thinking to reduce fragmentation and other inefficiencies in decentralized health systems.
  • The potential for digital health technologies to support the implementation of systems thinking in district health systems.

We welcome empirical studies, case studies, and reviews that draw on diverse disciplinary perspectives and methodologies. Our goal is to foster a deeper understanding of systems thinking methods and approaches in district health systems in low- and middle-income countries and to highlight its potential for improving health outcomes and health equity in these settings.

Thelen, J.; Sant Fruchtman, C.; Bilal, M.; Gabaake, K.; Iqbal, S.; Keakabetse, T.; Kwamie, A.; Mokalake, E.; Mupara, L.M.; Seitio-Kgokgwe, O.; et al. Development of the Systems Thinking for Health Actions framework: A literature review and a case study. BMJ Glob. Health 2023, 8, e010191.

Prof. Dr. Don De Savigny
Dr. Ntuli Angyelile Kapologwe
Guest Editors

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Systems is an international peer-reviewed open access monthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2400 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • systems thinking
  • systems dynamics
  • systems modeling
  • systems design
  • implementation research
  • one health
  • decentralization
  • fragmentation
  • low- and middle-income countries

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Published Papers (5 papers)

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19 pages, 1120 KiB  
Article
A Three-Stage Model for Innovation Adoption in Health Systems: Insights from the Health Promotion and System Strengthening Project in Tanzania
by Manfred Stoermer, Ally Kebby Abdallah and Karin Wiedenmayer
Systems 2024, 12(8), 300; https://doi.org/10.3390/systems12080300 - 13 Aug 2024
Viewed by 2097
Abstract
We explored the outcomes and challenges encountered during a 12-year collaborative development endeavor in Tanzania, focused on enhancing the healthcare system. The Health Promotion and System Strengthening (HPSS) project, supported by the Swiss Government and implemented by the Swiss Tropical and Public Health [...] Read more.
We explored the outcomes and challenges encountered during a 12-year collaborative development endeavor in Tanzania, focused on enhancing the healthcare system. The Health Promotion and System Strengthening (HPSS) project, supported by the Swiss Government and implemented by the Swiss Tropical and Public Health Institute (Swiss TPH) from 2011 to 2023, aimed to strengthen various aspects of Tanzania’s healthcare landscape. This included reforms in health insurance through the improved Community Health Fund (iCHF), the establishment of a public–private partnership to optimize the health commodity supply chain via a Prime Vendor System (Jazia PVS), the implementation of health technology management innovations, and the facilitation of participatory community and school health promotion initiatives. Operating in a multisectoral, interdisciplinary, and systemic manner, the HPSS project employed a variety of interconnected strategies, focusing on key entry points within the Tanzanian health system, starting from district level to national policies. These efforts followed a three-stages approach to reach a sustainable adoption of the innovations, going through the process of service and product innovation, integration into service delivery systems, and finally their adoption in the respective institutional policies. Each stage presented distinct frameworks and challenges, detailed in this article. The development of innovative concepts was complemented by capacity building through on-the-job training, establishment of new accredited training programs for pre-service trainings, and the development of new IT systems integrated into the governmental IT environment, as well as efforts to improve transparency, accountability, and governance. Activities in these fields were guided by operational research, following the translational approach of Swiss TPH to go from innovation and validation to application. The example of the HPSS project highlights the cycle of developing and testing innovations at the community and district level, followed by endeavoring national-level integration and policy adjustments, consequently resulting in improved service delivery at the district and community level. Full article
(This article belongs to the Special Issue Systems Thinking for District Health Systems: Applications, Issues and Challenges)
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16 pages, 2211 KiB  
Article
Systems Thinking for Supply Chains: Identifying Bottlenecks Using Process Mapping of a Child Health Intervention in the Democratic Republic of the Congo (DRC)
by Aliya Karim, Christian Burri, Jean Serge Ngaima Kila, Nelson Bambwelo, Jean Tony Bakukulu and Don de Savigny
Systems 2024, 12(4), 137; https://doi.org/10.3390/systems12040137 - 18 Apr 2024
Cited by 1 | Viewed by 1929
Abstract
The quality of supply chains in public health interventions in low- and middle-income countries can determine how effectively a program is able to treat its intended population group and subsequently achieve its health targets. We aimed to disentangle where challenges exist hierarchically and [...] Read more.
The quality of supply chains in public health interventions in low- and middle-income countries can determine how effectively a program is able to treat its intended population group and subsequently achieve its health targets. We aimed to disentangle where challenges exist hierarchically and administratively through the application of process mapping to the supply chain of an integrated community case management (iCCM) intervention in the Democratic Republic of the Congo (DRC). We conducted a document review, semi-structured key informant interviews, and focus group discussions with program agents involved in supply chain processes of the child health intervention. Enterprise architecture was used to map the intervention’s supply chain and its participatory actors, and detailed bottlenecks of the chain through the application of a health systems framework. The results of this study will be used to inform a system dynamics model of the supply chain of iCCM in DRC. The greatest bottlenecks leading to stockouts at the community level occurred upstream (from national to province and from zone to health facility). While the use of local procurement processes was partially attempted to strengthen systems, parallel supply chain activities compromised sustainable system integration and development. Initial delays in stock dispensation were due to international procurement at the supplier, inducing a trickle-down effect. Inadequate quantification of supply needs and subsequent insufficient product procuration were the single most important steps that led to stockouts. This study demonstrated that the community health supply chain would be most impacted by improvements made in processes at the highest administrative strata, while exposing its delicate dependence on activities at the lowest levels. Visibility of inventory at all levels and improved data quality and use through a transparent tracking system have the potential to significantly reduce stockouts. Future interventions should take care to not develop parallel processes or exclude local health system agents to avoid disruption and ensure sustainable health outcome gains. Causal loop studies and system dynamics can further identify the systems interactions and relationships and their underlying causal mechanisms in need of intervention. Full article
(This article belongs to the Special Issue Systems Thinking for District Health Systems: Applications, Issues and Challenges)
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15 pages, 749 KiB  
Article
Managing Local Health System Interdependencies: Referral and Outreach Systems for Maternal and Newborn Health in Three South African Districts
by Helen Schneider, Solange Mianda, Willem Odendaal and Terusha Chetty
Systems 2023, 11(9), 462; https://doi.org/10.3390/systems11090462 - 5 Sep 2023
Cited by 2 | Viewed by 4555
Abstract
In complex health systems, referral and outreach systems (ROS) are formal strategies for connecting and managing interdependencies between facilities in service delivery pathways. Well-functioning maternal and newborn ROS are critical to successful outcomes, and therefore, a good lens through which to examine the [...] Read more.
In complex health systems, referral and outreach systems (ROS) are formal strategies for connecting and managing interdependencies between facilities in service delivery pathways. Well-functioning maternal and newborn ROS are critical to successful outcomes, and therefore, a good lens through which to examine the management of local interdependencies. We conducted a qualitative study of maternal–newborn ROS, involving interviews with 52 senior, middle, and frontline managers, in three health districts of three different provinces in South Africa. We analyse the differences in functioning of ROS as an interplay of setting (urban, rural), individual facility strengths and weaknesses, the quality of emergency medical services (EMS), and the wider provincial strategic and organisational context. ROS are strengthened by sub-district governance arrangements that recognise and enable connectedness—in particular, between primary health care and district hospital services; by informal, day-to-day communication and collaboration across levels and professions; and by hybrid clinical–managerial players as system brokers and systems thinkers. We also identify leverage points, places where small shifts could have wider system effects, most notably in the design and functioning of EMS, and in addressing small, but significant bottlenecks in supply chains in lower level facilities that negatively impact the system as a whole. Full article
(This article belongs to the Special Issue Systems Thinking for District Health Systems: Applications, Issues and Challenges)
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22 pages, 4644 KiB  
Article
Towards Youth Mental Health System Reform: An Evaluation of Participatory Systems Modelling in the Australian Capital Territory
by Grace Yeeun Lee, Ian Bernard Hickie, Yun Ju C. Song, Sam Huntley, Nicholas Ho, Victoria Loblay, Louise Freebairn, Adam Skinner, Paul Crosland, Elizabeth Moore, Natalie Johnson, Stephanie Lentern, Josephine Brogden, Erin Barry, Catherine Vacher, Sebastian Rosenberg, Paul Mayers, Olivia Iannelli, Shin Ho Park and Jo-An Occhipinti
Systems 2023, 11(8), 386; https://doi.org/10.3390/systems11080386 - 28 Jul 2023
Cited by 1 | Viewed by 2460
Abstract
Australia’s mental health system is failing young people. Calls for accountability, strategic long-term policy planning, and regional leadership have been identified as solutions to guide mental health reform. Developing system dynamics models using a participatory approach (participatory systems modelling (PSM)) is recognized as [...] Read more.
Australia’s mental health system is failing young people. Calls for accountability, strategic long-term policy planning, and regional leadership have been identified as solutions to guide mental health reform. Developing system dynamics models using a participatory approach (participatory systems modelling (PSM)) is recognized as a useful method that can support decision-making for strategic reform. This paper reports evaluation findings of a youth mental health PSM process conducted in the Australian Capital Territory (ACT). Baseline and follow-up mixed-methods evaluation data were collected in 2022 across diverse stakeholder groups to investigate the feasibility, value, impact, and sustainability of PSM. Although youth mental health system reform was viewed as desirable and a necessity across all stakeholder groups, shared perceptions of disabling powerless was observed regarding their ability to influence current decision-making processes to improve the youth mental health system. This suggests greater accountability is required to support systemic reform in youth mental health. PSM offers promise in improving transparency and accountability of decision-making for youth mental health, as exemplified in the ACT. However, more support and time are required to facilitate transformational change. Future research should investigate empowerment strategies to complement the implementation of findings from dynamic models developed through PSM, as well as the effectiveness of regional youth mental health policy decision-making supported by systems modelling. Full article
(This article belongs to the Special Issue Systems Thinking for District Health Systems: Applications, Issues and Challenges)
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11 pages, 513 KiB  
Study Protocol
Combining Theory-Driven Realist Approach and Systems Thinking to Unpack Complexity of Type 2 Diabetes and Hypertension Management in Low and Middle-Income Countries: Protocol for a Realist Review
by Fatemeh Ehteshami, Rachel Cassidy, Fabrizio Tediosi, Günther Fink and Daniel Cobos Muñoz
Systems 2024, 12(1), 16; https://doi.org/10.3390/systems12010016 - 6 Jan 2024
Viewed by 2454
Abstract
The burden of type 2 diabetes mellitus (T2DM) and hypertension (HTN) has increased worldwide in recent decades, particularly in low- and middle-income countries (LMICs). In these countries, health systems often struggle to provide effective health care services for the management of chronic conditions. [...] Read more.
The burden of type 2 diabetes mellitus (T2DM) and hypertension (HTN) has increased worldwide in recent decades, particularly in low- and middle-income countries (LMICs). In these countries, health systems often struggle to provide effective health care services for the management of chronic conditions. We have developed a study protocol with the aim of conducting a realist review to delve into the complexities behind the management of T2DM and HTN in LMICs. First, we have developed a causal loop diagram (CLD) serving as the initial program theory to represent the health system drivers associated with the effective (or ineffective) management of T2DM and HTN. Next, we will search, select, appraise, extract and analyze the relevant evidence. This evidence will be used to refine and extend the initial program theory to transform it into a middle-range program theory. This will then be verified through Group Model Building (GMB) sessions. The evidence will be summarized applying RAMESES (Realist And MEta-narrative Evidence Syntheses: Evolving Standards). In combining a systems thinking approach with a realist approach to program evaluation, we aim to unravel the mechanisms that govern the management of T2DM and HTN, and the relation between health system-related factors, which lead to outcomes, in different contexts. Full article
(This article belongs to the Special Issue Systems Thinking for District Health Systems: Applications, Issues and Challenges)
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