IAPB 9 th General Assembly Eye Health: Everyone’s Business Hyderabad, India September 17-20, 2012 What are Health Systems? And why should we engage? Prof. Don de Savigny Health Systems Research Department of Epidemiology and Public Health

Health System Conceptual Foundations

Health systems for eye health: Everyone’s business

Key social goal… Improve health by average level of population health health inequities Health systems “ All organizations, people and action whose primary intent is to promote, restore or maintain health” WHO, 2007

Basic health system framework INPUTS & PROCESSES Governance Finances Human resources Medicines, technologies & infrastructure Information INPUTS & PROCESSES Governance Finances Human resources Medicines, technologies & infrastructure Information OUTPUTS Service delivery efficiency access availability affordability acceptability quality safety OUTPUTS Service delivery efficiency access availability affordability acceptability quality safety OUTCOMES Increased effective coverage responsiveness OUTCOMES Increased effective coverage responsiveness IMPACTS Improved survival nutrition equity Reduced morbidity impoverishment due to health expenditures IMPACTS Improved survival nutrition equity Reduced morbidity impoverishment due to health expenditures OTHER DETERMINANTS OF HEALTH (Economic, Social, Political, Environmental) OTHER DETERMINANTS OF HEALTH (Economic, Social, Political, Environmental) Modified from: WHO Everybody’s business, 2008 & Health Metrics Network Framework, 2008 But is this simple linear logic the way things really work?

Health systems A tightly inter-woven framework of building block sub-systems Source: de Savigny and Adam (2009) “What happens in the spaces between the sub-systems is as important as what goes on within them; and is usually neglected”.

System = Whole A system is: any collection of related parts that interact in an organized way for a purpose

Characteristics of all complex systems And …. nest sub-systems within them but are part of larger systems

Example of non-linearity & perverse effects 1. Reimbursement for severe malaria set too high 3. Health Information system records a rise in severe malaria 2. Providers capture more profit by diagnosing more severe malaria = Reduced access to correct malaria treatment and higher OOP 5. Drug stock-outs at health facility; Quality drops 4. Lag in procurement of 3rd line drugs for malaria

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: (2006).

Systems thinking involves shifting attention…  from the parts to the whole,  from objects to relationships,  from structures to processes,  from hierarchies to networks,  from the rational to the intuitive,  from analysis to synthesis,  from linear to non-linear thinking. Adapted from Fritjof Capra

System thinking skills Usual approachSystems thinking approach Static thinkingDynamic thinking focus on eventsfocus on patterns of behaviour

System thinking skills Usual approachSystems thinking approach Static thinkingDynamic thinking focus on eventsfocus on patterns of behaviour Systems as effectSystems as cause behaviour as externally drivenresponsibility for behaviour from internal actors and rules

System thinking skills Usual approachSystems thinking approach Static thinkingDynamic thinking focus on eventsfocus on patterns of behaviour Systems as effectSystems as cause behaviour as externally drivenresponsibility for behaviour from internal actors and rules Tree-by-tree thinkingForest-thinking knowledge from understanding detailsknowledge from understanding contexts of relationships

System thinking skills Usual approachSystems thinking approach Static thinkingDynamic thinking focus on eventsfocus on patterns of behaviour Systems as effectSystems as cause behaviour as externally drivenresponsibility for behaviour from internal actors and rules Tree-by-tree thinkingForest-thinking knowledge from understanding detailsknowledge from understanding contexts of relationships Factors thinkingOperational thinking concentrating on factors that influence or correlate concentrating on how behaviour is generated

System thinking skills Usual approachSystems thinking approach Static thinkingDynamic thinking focus on eventsfocus on patterns of behaviour Systems as effectSystems as cause behaviour as externally drivenresponsibility for behaviour from internal actors and rules Tree-by-tree thinkingForest-thinking knowledge from understanding detailsknowledge from understanding contexts of relationships Factors thinkingOperational thinking concentrating on factors that influence or correlate concentrating on how behaviour is generated Linear thinkingLoop thinking view causality running in one directionView causality as an on-going process with feedback influencing causes

System phenomena: Feed back loops Explains: - vicious circles, - stock and flow problems, - price & demand modulation, - and why standardized approaches continue to serve the same populations but fail to reach the poor. When the outcome of a system process is the input in the same system Adapted from: Paina & Peters (2012)

System phenomena: Path dependence Different, non-reversible processes from similar starting points. Outcomes sensitive to initial conditions and choices along the way. Why solutions that work in one country may not work in another. Adapted from: Paina & Peters (2012)

System phenomena: Emergent behaviour Spontaneous creation of order when smaller entities jointly contribute to organized behaviour as a collective where the whole is greater and more complex than the sum of the parts. Adapted from: Paina & Peters (2012)

Social Network Analysis Disappearance of a broker resulted in 179 dropped ties across districts. SNA software allows quantitative analysis of network density, distance, centrality, information flows. Blanchet and James (2012)

System phenomena: Scale free networks Networks dominated by few focal points or hubs with unlimited connections follow power-law distributions Explains disproportionate effects of influencing hub individuals Adapted from: Paina & Peters (2012)

Systems thinking Pushing harder and harder on familiar solutions, while fundamental problems persist or worsen, is a reliable indicator of non-systems thinking – the "what we need here is a bigger hammer" syndrome Peter Senge, 1990

Leverage points when intervening in a system (in increasing order of effectiveness) 9. Constants, parameters, numbers, subsidies 8. Regulating negative feedback loops 7. Driving positive feedback loops 6. Material flows 5. Information flows 4. Rules of the system (incentives, constraints) 3. Distribution of power over the rules of the system 2. Goals of the system 1. The mindset or paradigm out of which the system -- its goals, power structure, rules, culture arises. Modified from Donella Meadows

Small changes can produce big results ! -- but points of highest leverage are least obvious There are no rules for finding tipping points, but there are ways of thinking that make it more likely. Learning to look system-wide and see underlying processes, approaches and contexts rather than "events" is a starting point... “Systems Thinking” is the language and “Systems Science” is the discipline Approaching 2020 will benefit from increasingly sophisticated approaches to tipping points in complex adaptive health systems