Systems

Thinking:
for Health Systems Strengthening

Alliance for Health Policy

& Systems Research
Flagship Report Series

Don de Savigny
Swiss Tropical and Public Health Institute

Taghreed Adam
WHO Alliance for Health Policy and Systems Research

WHO Geneva, February, 2010

 Foundations

2000 2007 2008 2009

 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.

 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 3:956-960 (2006).
 System building blocks and values

WHO 2007: Everybody's’ Business. Strengthening health systems to improve health outcomes
 Health systems are
more than the building blocks

How do we work them together for a more

high performance system?
WHO 2009: Systems thinking for health systems strengthening
Characteristics of all complex systems

And ….
• nest sub-systems within them
• but are part of larger systems
Skills of systems thinking
All health interventions have
system-wide effects
Contemporary
system-level
interventions
A system-wide view of intervention design
 Key components and
evaluation research questions
What questions does the report address?

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9 How
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9 How
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us
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understandand andexploit
exploit
synergies
synergiesforforsystem?
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9
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betterevaluations
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system-
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strengtheninginterventions?
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 Some key messages from chapters
• With leadership, conviction and commitment, systems
thinking can open powerful pathways to identify and
resolve health system challenges;

• Health system stewards can use systems thinking to

increase local ownership of multi-stakeholder processes
and respond to the dynamic of disease-specific,
sometimes donor-driven “solutions”;

• Engaging “street-level” policy implementers at the

design stage of new interventions can enhance
ownership of the intervention and increase the potential
for successful implementation;

• Strengthening of leadership and governance of health

system stewards is crucial in strengthening health
systems
 Select challenges in applying
a systems perspective
• Aligning policies, priorities and perspectives
among donors and national policy-makers;

• Managing and coordinating partnerships and

expectations among system stakeholders;

• Implementing and fostering ownership of

interventions at the national and sub-national
level;

• Building capacity at the country level to apply a

systems analytic perspective
 Ideas for moving forward

• A task force on systems thinking for health systems;

• A systems thinking network or community of practice;

• Building capacity of system stewards;

• Systems thinking methods development;

• Health systems dynamic modeling;

• Applying the systems thinking steps in future HSS investments;

• Systems thinking in public health training curricula;

• An open-source Journal of Health Systems Development.

Implications for WHO's work with countries

• Make the case for using a systems perspective in solving systems problems
and in designing new interventions

• Encourage systematic evaluation of new and ongoing interventions to

strengthen health systems

• When evaluations of health systems efforts are made, advocate for the
need to consider system-wide effects to develop "system-wise" solutions

• Remember that results of evaluations only relevant for a short time--

interventions should be re-evaluated on a regular basis and will likely need
to be redesigned

• Consider to strengthen national HSR capacity to understand systems from a

governance and systems behaviour perspective

• Implications for the Alliance HPSR --a new stream of work to push this
agenda forward, together with interested partners
Need to invest in developing our thinking

" It is never been put so explicitly that

countries really need to invest in “thinking” and
“thinkers” (rather than the usual focus on tool
development) so that they can assess and adapt
to their particular context and challenges."

Joe Kutzin, WHO, Euro.

The report
• Available in hard copy at this session

• Available in English, French and

Spanish

• Available in pdf downloads at:

http://www.who.int/alliance-hpsr/en/

• Everyone welcome to pick up a

copy…

• Review and feedback welcome by

email
Thank you