We believe that systems thinking and complexity science can be transformational in global health by increasing local capacity and shared learning, and minimizing unintended consequences.
1. Systems Principles: Health systems stewards apply systems principles. Health systems are holistic, interdependent, constantly changing, and counter-intuitive; they are more than the sum of their parts . As such, global health planners should consider the impact that their activities will have on all of the major components, processes, and relationships in the health system when attempting to strengthen (or minimize the negative impacts on) it. Just because an intervention strengthens one component (or even several components) of the health system (such as service delivery) does not necessarily mean that it strengthens the entire system. Indeed, it may even weaken the overall system while strengthening one component. As such, all of the principles listed below must be considered; neglecting even one could lead to systems weakening. It seems like we should focus on these three systems principles (see Systems Thinking for HSS, p. 40):
• Holism: “no individual agent or element determines the nature of the system”
• Leverage: “seeing where actions and changes in structure can lead to significant, enduring improvements” (P. Senge’s “The Fifth Discipline,” p. 114).
• Counter-intuitive: highlights the need for broad and continuous monitoring.
2. Effectiveness and Efficiency: Strong health systems improve and maintain health in the most efficient manner possible.
a. Allocative Efficiency: The global health funding focus should match the current and anticipated future need of the population.
b. Structural Efficiency: The structure of health systems should match the population’s need. Duplication and disruption of partner countries’ health activities should be avoided.
c. Technical Efficiency
3. Capacity Enhancement: HSS activities develop human and institutional capacity long-term.
a. New public health challenges are most efficiently addressed by trained locals.
b. Behavior change and institutional development takes many years. Programs should consider this when planning time-lines.
c. Development and maintenance of effective leaders and management plans is crucial.
d. Quality assurance is a cyclic, iterative, gradual process that must be planned for.
e. Recipient collaborators should be allowed the development of “ownership” of programs, data, and research capabilities, and be accountable for their results.
4. Social Mobilization and Change: Recognizes that ill health is at least as much a social problem as it is a biomedical one.
a. Public health successes depend on social change.
b. Health systems should be structured and develop incentives to adequately impact the social determinates of health.
a. Performance indicators should be disaggregated to reveal inequity in disenfranchised populations.
b. Service delivery approaches should target those that need them most.
c. Those with the poorest health should be empowered by inclusion in health planning and implementation, and frequent consultations with them.
6. Customer Satisfaction:
7. Financial Protection:
8. Intersectoral Collaboration: The importance of the social determinates of health require that health systems actors be leading advocates in issues such as education, gender equality, and poverty reduction. They must develop relationships with leaders in those fields, be effective communicators, and be active and political and advocacy activities.
9. Local Context: All of the principles and guidelines above, and the process of deciding how much to consider each one, are context specific. Local communities and nations will need to decide how to measure health status and customer satisfaction, for example.