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.
We believe the following ten resources to be great systems thinking and complexity in health resources for health professionals in all fields seeking to apply these ideas to their work.
1. No list of systems thinking resources would be complete without includingSystems thinking for Health Systems Strengthening by the Alliance for Health Systems Research and WHO Geneva. This is the third in a series of flagship reports by the Alliance for Health Systems Research and has had a widespread, and increasing influence. This Report provides a realistic understanding of effective approaches to strengthening systems, especially in low-income countries and global health initiatives. The report also outlines simple steps to take when seeking to apply the often-elusive systems thinking. The ten steps it gives to applying systems thinking to a health system are (1) convene stakeholders, (2) collectively brainstorm, (3) conceptualize effects (4) adapt and redesign, (5) determine indicators, (6) choose methods, (7) select design, (8) develop plan, (9) set budget, (10) source funding. The primary goal of the report “is to catalyze new conceptual thinking on health systems, system-level.” It also defines key concepts, terms, and methods in systems thinking and has been effective in increasing collaboration and shared learning within the discipline, being cited numerous times since its publication in 2009.
2. Possibly the seminal work on considering complexity science as it relates to health is the BMJ Complexity Science Series by Plesk published in 2001. This series is one of first major considerations of complexity science in health, and delves into how complexity science relates to health education, healthcare management and leadership, and clinical care. The series contains four articles that address key issues within healthcare that are affected by increasing complexity, offering relatable examples for professionals in the field. The article in this series, “Coping with Complexity: Educating for Capability” discusses the ever changing environment of education and the need for capacity building education that enables the learner to act and adapt to emerging challenges. In the same vein, the articles dealing with clinical care talk about the importance of adaptability of physicians due to the complexity of today’s health issues, outlines this importance through the control of blood glucose levels in diabetes, the management of diagnostic uncertainty, and health promotion. Another important and fundamental principle this series addresses is that healthcare organizations function less like machines and more akin to complex adaptive systems. Despite it’s publication in 2001, this series remains a key resource and building block for complexity science in health.
3. The American Journal of Public Health recently compiled a series of articles relating to systems thinking in public health that has been monumental. This 2006 series contains 25 articles relating to different public health fields and is titled Systems Thinking and Modeling in Public Health Practice. This series touches on many disciplines within public health including research, practice, promotion, policy, and education. The editor of this series makes the point that system thinking has no single discipline because it is inherently focused on the linkage of disciplines. Therefore this series is directed at a very broad range of disciplines within public health that can be improved through systems thinking. The editor also makes the point that as systems thinking is applied to our various fields of work we should keep 4 key lessons in mind. “First, at the heart of a systems orientation is an emphasis on relationships . . . Second, efforts to achieve a larger, more connected understanding of the public health enterprise must never obscure the continuing need for specialized studies, on which all good systems theory depends . . . Third, a systems approach to health and health care dilemmas requires us to transcend academic boundaries and interact more effectively across organizational lines as we learn to understand and manage ever more complex challenges . . . [and] fourth, many aspects of systems thinking have ancient philosophical roots, and their modern methodological manifestations are phenomenally diverse.”
4. Perhaps the most extensive collection on complexity in healthcare is a forum produced by the Journal of Evaluation in Clinical Practice titled: Forum on Systems and Complexity in Medicine and Healthcare. This collection began in 2009 and has continued to add impactful articles dealing complexity and systems in healthcare. This forum was born from Carmel Michael’s and Joachim Sturmberg’s recognition of the void in rigorous complexity research and practice in medicine, despite the inherent complexity in health and its delivery. This impressive collection includes dozens of articles on a wide range of topics, from health promotion to healthcare reform with the goal of providing accessible information on how to address the complexity of the health problems we face, as well as the complexity of the health systems practitioners operate in.
5. Another key resource in systems thinking is a follow-up to Systems Thinking for Health Systems Strengthening. After the successful publication of that article Health Policy and Planning compiled a short series more specific to global health interventions titled Systems thinking for health systems strengthening in LMICs: seizing the opportunity. This series provides detailed examples of systems thinking applications around the world that organizations and professionals can reference when developing and implementing programs. This series is especially impactful, because up until its release, there were few case studies of systems thinking and evidence that it had been applied successfully. This series also acts as a call to action for global health workers everywhere to shift the paradigm they are currently operating in, to a systems thinking approach.
6. Possibly the most comprehensive consideration of a specific topic from a systems perspective is the Tobacco Monograph: “More than the sum”sponsored by the National Cancer Institute. This 275-page document is foundational for applying systems thinking to various health issues, providing a major example for professionals everywhere. Systems thinking in health lacks many rigorous case studies, thus this monograph is a particularly influential document for providing a framework for future systems thinking applications. The ISIS project identified four key systems thinking approaches that were instrumental in understanding and addressing the tobacco control problem. These approaches are systems organizing, systems dynamics, systems networks, and systems knowledge. Through these approaches they were able to successfully model the systems involved in tobacco control and develop plans and interventions to address the problems faced. In attempts to understand the current system, ISIS defined a few important aspects of the system and what it meant. The systems issues they defined are as follows:
Understanding the system provided a framework for decision making and understanding. This document can be instrumental for the health professional trying to understand how to apply a systems framework to the issues they face in their own work.
7. Another fundamental resource is chapter 7 of the book Health Systems and the Challenge of Communicable Disease titled Health Systems and Systems Thinking by Rifat Atun and Nata Menabde. This chapter provides a historical and theoretical overview of systems thinking as it relates to health systems. In doing so, the resource successfully defines what a health systems really consist of, citing the WHO relating that health systems include all activities whose primary goal is to promote, restore, or maintain health. The chapter continues to define how we measure the performance of health systems, and how we analyze health systems reform, which is a major issue that many countries face. This document is considered to be a top resource in systems thinking because of it’s focus on the basic overview on systems thinking which can act as a backbone for further studies and research in the field. It also outlines the drivers of the dynamic complexity within systems, which are the presence of feedback loops, time lags between cause and effect, and non-linear relationships between elements and actors within the system. Health systems and Systems Thinking also effectively connects the overlap between systems thinking and complexity, as the difference can often seem unclear.
8. Appendix B of the influential publication Crossing the Quality Chasm in IOM is another important source to the study of complexity called Redesigning Health Care with Insights from the Science of Complex Adaptive Systems. Appendix B gives a very understandable description of health as a complex adaptive system using real world analogies that simplify the often elusive complexity terminology. As heathcare reform is currently a very important topic, this publication is especially timely and influential to policy makers in government as well as front line workers implementing changes. This article also discusses the contrast between current mechanical views of the health system and the more realistic complex adaptive nature of our healthcare system, and details reductionisms role in the past while this article provides the Stacey Diagram: Zone of Complexity, which illustrates the complexity or chaotic state of the decisions made based on certainty about Care with Insights from the Science of Complex Adaptive Systems is especially necessary for this list because of the simplicity in which in describes this hard to understand principles, proving a great overview of the topic for the unfamiliar health professional.
9. Another key resource is Understanding pathways for scaling up health services through the lens of complex adaptive systems by Ligia Paina and David Peters. This publication submits that current global health approaches to scaling up are inadequate. The way many organizations and governments currently approach global health initiatives is what many refer to as the blueprint approach, where one plan is develop and applied to all situations and contexts. However this article suggests that this is ineffective and that today’s health systems function more like complex adaptive systems that require action based on local context. Paina and Peters outline key complexity science concepts, and examples of their application to health as a potential solution. “Based on an understanding of complex adaptive systems behavior, [this article] describe[s] how phenomena such as path dependence, feedback loops, scale-free networks, emergent behavior and phase transitions can uncover relevant lessons for the design and implementation of health policy and programs in the context of scaling up health services.”
10. The last of the ten best resources in systems thinking and complexity science in health comes from Health Education and Behavior in a supplemental issue titled Systems Science Applications in Health Promotion and Public Health. This supplemental issue is a rigorous collection of articles that demonstrate the wide range of applications of systems methods and perspectives to health promotion and public health. This publication stems out of the lack of systems and complexity science education being taught in current educational institutions and professions and seeks to give an understanding of the potential systems sciences have in health today. This supplement also seeks to promote future collaboration among existing and emerging scholars seeking to understand how to address health issues, by providing in depth examples and a comprehensive foundation of the basic terms and methods systems and complexity science offers. This supplement includes 13 articles that give a broad perspective on systems sciences both from a theoretical point of view and from former successful systems concept applications in health systems around the world.