Introducing a new resource for applied systems thinking methodologies for health systems researchers
In October this year, Don de Savigny, Karl Blanchet and Taghreed Adam published Applied Systems Thinking For Health Systems Research: A Methodological Handbook. This book presents a collection of methods chapters, underpinned by real world experience, describing some of the main innovative systems thinking approaches, methods and tools being used in health systems research today. Given the high level of interest in systems thinking and the desire of students, researchers and professionals to apply systems thinking ideas in their work, this publication could be a very useful teaching resource. In this blog, Don de Savigny writes about the origins of the handbook, the approaches and tools it covers, and how it can be used in teaching.
Foundations and motivation
Health systems are complex adaptive systems. As such they are characterized by extraordinary complexity in relationships among stakeholders and the processes they create. Systems phenomena of connectedness and interdependencies, self-organizing and emergent behaviour, non-linearity and lagged feedback loops, path dependence and tipping points, all make health system behaviour difficult to predict, manage or study.
Conventional reductionist approaches to epidemiologic and implementation research are not fully adequate for tackling the messy problems health systems pose. It is increasingly recognized that health systems and policy research needs special approaches, methods and tools that derive from systems thinking perspectives. This we now appreciate, but it was not always the case.
Julio Frenk first drew our attention to systems thinking for health systems (and not just diseases or programme management) in remarks he made in 2008 on the occasion of the 30th anniversary of the Alma Ata Declaration on Health for All. He said systems thinking would be the revolution we need to help us transcend the complexity of health systems. At the time, there was little evidence of this happening.
Fortuitously, at the same time the Alliance for Health Policy and Systems Research (AHPSR) was looking for a topic for its next flagship report and the idea for systems thinking as a theme arose. Taghreed Adam from the AHPSR and I worked on this and produced Systems Thinking for Health Systems Strenghtening. It became a very popular plain language primer that linked systems thinking to the World Health Organisation health systems building blocks framework of the day.
Following that publication, a frequent refrain from readers was that they understood and appreciated the concept, but wanted to know how they could apply it in their work: what approaches, what methods? Subsequently there was an exponential rise in the number of applications of systems thinking in health systems and policy work (Carey et al., 2015; Chughtai & Blanchet, 2017), much of which was supported by the AHPSR and the International Development Research Centre and spurred on by Health Systems Global and its biennial symposia.
This was documented in some key theme issues from journals, most notably Health Policy and Planning and Health Research Policy and Systems. And this body of work has started to provide an empirical base of experience with useful approaches, tools and methods that was comprehensively catalogued by David Peters in 2014.
At that point we decided the time was right and the demand was growing for a methodological handbook drawing attention to a suite of tools and approaches that could be used across the life cycle of health systems and policy research endeavours. This is now complete and available from Open University Press. Digital copies can be made available to students in registered courses on arrangement with the publisher.
Why are systems thinking tools important for health systems research?
The behaviour of complex health systems is determined by the actions of the actors and institutions involved and the power and politics that operate between them. Systems thinking emphasizes the interactions and connections among the different actors that make up a "system", as well as the importance of feedback loops and process contexts that make systems behaviour "messy".
Research that is conducted at the intersection of health systems and health policy is by nature concerned with system functioning and policy change (rules of the system). Systems thinking helps research move beyond the conventional linear approach or even the iterative approach of research-to-policy-to-implementation-to-evaluation-to-further research, etc. Health systems research from this perspective is at odds with linear models of the policy process.
Intended audience and use of the handbook
This handbook is aimed at providing guidance to students, researchers and professionals who want to apply emerging systems thinking approaches and methods in health systems research. It is intended to be a practical learning tool, covering well tested and practical aspects of systems thinking methods, tools and techniques useful in health systems research.
It has been designed to be a comprehensive how-to guide for students, academics, research users and other health professionals. Its purpose is to prepare researchers and system managers to apply these principles and practices immediately to their own complex health system challenges.
Every chapter is written by one or a team of authors selected for their applied expertise. Each chapter is in two parts. The first starts with a historical overview of the method, its theoretical underpinnings and a clear description of the method, while the second provides a practical, real world application of the method to illustrate how it can be implemented to tackle a relevant health system research challenge.
Systems thinking approaches and tools covered in the handbook
The systems thinking research methods and approaches in the handbook can be loosely ordered and described under two overlapping themes: a) tools for identifying and understanding problems and framing the research questions; and b) tools for determining and managing solutions. Almost all the tools have a strong emphasis on the actors and stakeholders in the system, and in the processes that they undertake. The following is a brief overview of what is covered.
In this handbook, we have selected methods and approaches that collectively could be used across the life cycle of any research project: deciding how the research team should be fully aware of the system they study, determining the boundaries of the system under study, identifying and analysing the stakeholders concerned, identifying and framing the system problem(s) to be studied, identifying potential solutions, addressing and negotiating decision making processes, testing and modelling solutions, and monitoring and evaluating system-level interventions.
Jill Olivier, Vera Scott, Dintle Molosiwa and Lucy Gilson set the stage for the handbook with their fascinating essay "Systems approaches in health systems research – approaches for embedding research", where they address the emerging concept of embedding research in the health system itself. This is then followed by a series of chapters on the approaches to describing, analysing, changing and managing situations.
The matrix below links research needs to the various methods described in the handbook and indicates which methods have associated visualization features or specific software applications.
Taken together we hope the approaches provided in the handbook will make it easier for students, health researchers, and health system managers to move beyond systems thinking theory to real world applications for complex health system problems.
Of course, one does not need to apply all of these methods in each study, but almost every health system research endeavour would benefit from applying at least one of these systems thinking methods. Collective judgment will be needed in selecting which of the many qualitative and quantitative methods or tools described here will be most useful in particular settings.
Doing so would reinforce the ability to perceive the system as a whole, and take stakeholders beyond relying on implicit mental models of how the system behaves, towards more objective and evidence-based models. Moreover, many of the tools engage stakeholders in ways that improve communicating on, and collectively better understanding, the complexity of the system such that negotiating, deciding and owning interventions is made easier.
The common theme of all of these systems thinking methods is that systems behaviour is governed by common principles that can be identified and better understood, and in so doing, system outcomes can be better documented and predicted, thus facilitating the development of interventions for the amplification of good outcomes and the damping of bad outcomes.
We hope greater application of systems thinking methodologies in health systems research will provide new opportunities to understand, communicate, test and intervene effectively in complex health systems.
Don de Savigny, Professor, Health Systems and Policy Research, Swiss Tropical and Public Health Institute