By Dintle Molosiwa.
How can we develop more effective interventions that address root causes of insufficient system performance? How can systems-informed interventions achieve and sustain more impactful system improvements? What strategies ensure multisectoral collaboration in systems improvement initiatives?
This i2Insights contribution is based on experience in improving health systems in South Africa, Senegal, Zambia, Botswana and Chemonics global health supply chain portfolio, but is likely to have wider relevance for other systems and countries.
Colleagues and I (Chemonics Health Practice and SYSTAC Africa Hub, 2024) distilled existing system thinking frameworks into a four-step cycle: examine; co-create; implement and adapt; and adopt and scale.
1. Examine. Apply systems thinking concepts, models, and tools to strategically analyze systemic challenges that affect sustainable system improvements. These analyses serve to:
- describe system components and understand their relationships, interactions, and behaviors;
- identify leverage points with potential to catalyze desired change;
- understand drivers and root causes of low performance to be addressed.
2. Co-create. With communities and other system actors, co-develop interventions informed by findings from Step 1 (Examine). This may result in a list of system changes targeting structural (building blocks) and functional (process-focused) system components and relationships. Practitioners should anticipate potential adverse or unwanted effects of system changes during co-creation.
3. Implement and adapt. Carry out and measure interventions in short iterations, then evaluate their feasibility and sustainability, assessing positive and negative system changes. Based on these observations, return to Step 1 (or revisit co-creation) and adapt interventions based on this deeper or updated understanding of system dynamics.
4. Adopt and scale. Carry forward interventions that are feasible and sustainable.
In our work we developed three guiding principles to incorporate into the existing cycle to address barriers: I) nurture local champions as systems-thinking practitioners; II) diversify and strengthen collaboration across systems and sectors; and III) measure system thinking in terms of improved resilience.
Principle I: Nurture local champions as systems-thinking practitioners
- Meaningful systems change can only be achieved with effective, empowered leaders. They must be willing and able to navigate uncertainty, interpret system responses, generate and share learnings, and swiftly adapt decisions and strategies, all while fostering inclusive environments for continuous improvement.
- Because local actors are best positioned to create and sustain locally responsive solutions, investments are needed to build local champions and strengthen their capacity to sustain improvement cycles and institutionalize processes for systemic change.
Principle II: Diversify and strengthen collaboration across systems and sectors
- Effective systems thinking brings together diverse system stakeholders to use tools, examine system challenges holistically, and co-create interventions. In the health system for example, these stakeholders can include decision-makers, patients, healthcare workers, private sector representatives, and community leaders.
- Stakeholders often learn that the challenges to improving the system extend beyond traditional actors. Again drawing on experiences from the health system, non-health policies, institutions, resources, and development interventions significantly contribute to social, political, economic, cultural, and commercial health determinants, even though they are not primarily centered on health and are not part of the health sector. These determinants include economic stability; education access and quality; neighborhood and built environment, including water, energy, and transport sectors; and the social and community context.
- Multiple sectors should be invited to address the full range of underlying, non-traditional contributors. While involving everyone in a systems-thinking effort is prohibitive, it is important to bring diverse actors to the co-creation table to encourage a multisectoral perspective and multiple viewpoints. This will also allow the group to identify potential negative side effects of well-intentioned changes on other sectors and adapt best practices for their context.
Principle III: Measure systems thinking in terms of improved resilience
- Systems thinking is most effective when it is operationalized locally and continual applications are sustained over time. It promises to contribute to making the system better at performing its essential functions, as well as making the system more resilient to shocks and stressors.
Contributing to greater system resilience requires:
- Using systems thinking tools, especially in Step 1 (Examine), to generate a deeper and broader awareness of the system, its components, and their interrelatedness.
- Forging multisectoral connections improves the system’s capacity to address a diverse range of challenges, detect shocks and stressors as they arise, and engage more non-traditional sectors that contribute to better outcomes.
- Local systems become more self-regulating as empowered local leaders leverage local resources to implement solutions. This increased absorptive capacity also relates to the existing ability of a system to take intentional protective action and maintain stability in the face of known shocks and stressors to prevent or limit negative impacts.
- As systems thinking is practiced, system actors glean deeper insights into the relevant system and can adapt solutions accordingly. System adaptive capacity is demonstrated through improved ability to make incremental and flexible adjustments to manage a changing environment better while improving overall system performance.
- By its nature, systems thinking promotes integration and seeks to address common underlying challenges, rather than siloed approaches, for a more lasting impact. System transformative capacity refers to the ability of the relevant system to make fundamental functional and structural changes that address underlying challenges and contextual dynamics that impact performance and progress toward improved outcomes.
Measuring the impact of using systems thinking is challenging. Not only is it difficult to directly attribute results to a single intervention, but there are also not yet standard indicators for measuring improvements in systems resilience. Systems thinking practitioners can:
- co-develop indicators and measurement approaches alongside interventions to identify both incremental changes and overall system shifts
- benefit from measuring the unintended, unexpected, or unplanned positive and negative impacts of a systemic intervention so as to demonstrate the broader value of systems thinking
- educate peers and donors about the need to shift mindsets to accept uncertainty and explain that there might not be impact results at the end of five-year program cycles.
What has your experience been with intervening in systems (other than health, if applicable) to improve them? In what ways does our experience of applying systems thinking in healthcare resonate with your experience in any other field?
To find out more:
Chemonics Health Practice and SYSTAC Africa Hub. (2024). Approach for operationalizing and sustaining systems thinking for health. Technical Brief, Chemonics Health Practice and SYSTAC (Systems Thinking Accelerator) Africa Hub: place of publication not provided. (Online – open access): https://chemonics.com/wp-content/uploads/2024/11/Systems-Thinking-for-Health-Technical-Brief_Final.pdf (PDF 733KB)
The report provides references and case examples. Much of the text of this i2Insights contribution is taken verbatim or only slightly modified from this technical brief.
Use of Generative Artificial Intelligence (AI) Statement: Generative artificial intelligence was not used in the development of this i2Insights contribution. (For i2Insights policy on generative artificial intelligence please see https://i2insights.org/contributing-to-i2insights/guidelines-for-authors/#artificial-intelligence.)
Biography: Dintle Molosiwa PhD is a member of Health System Global, a global society committed to advancing research on health policy and systems. She is also a Lecturer in the Department of Family Medicine and Public Health at the University of Botswana in Gaborone, Botswana. Her areas of interest focus on health professional education and health policy, aimed at improving healthcare leadership and governance, health service delivery and health equity.