Systems Thinking approaches for more resilient health systems during COVID-19

Funded by the Alliance for Health Policy and Systems Research (AHPSR), the Swiss Tropical and Public Health Institute (Swiss TPH) hosts a Technical Support Centre (TSC) with expertise in health systems resilience and district-level health systems strengthening. The Centre has been facilitating the adaptation of systems thinking tools, and exchanging about how to achieve system-wide change with district health management teams in Botswana, Pakistan and Timor-Leste since the onset of the pandemic. Swiss TPH works together with institutions in each country to achieve this endeavor: the Institute for Development Management in Botswana, Child Advocacy International in Pakistan and the World Health Organization for the country office in Timor-Leste.

The Systems Thinking for District Health Systems initiative was launched in November 2019. The original approach included mostly the work of each national institution together with the TSC at Swiss TPH to adapt and apply systems thinking tools to the needs of district health managers. The TSC was going to facilitate the adaptation, capacity building and monitoring of the initiative.

How the pandemic forced us into new forms of cooperation and exchange

In March 2020, driven by the ongoing challenges of the COVID-19 pandemic, we had to rethink how we would operationalize the initiative, as face-to-face implementation became impossible. This shift led to the creation of an online District Systems Thinking Community of Practice (CoP). The CoP emerged as a way to conduct capacity-building activities and establish a structure to learn from each other.The CoP sessions became a place for exchange and discussion, instead of vertical capacity building, which indirectly led to a more equal partnership, with multidirectional learning.

Before the pandemic began, the TSC had organised a 3-day preparatory workshop with the institutions in which the main concepts of systems thinking were introduced and some practical examples of the use of systems thinking tools (decision space, reflective practice and embedded research) were given. The workshop aimed to provide practical skills to participants in the use of systems thinking approaches and tools and provided a basis for the whole initiative.

Moreover, from the very outset, the TSC aimed to facilitate peer-to-peer learning and build on the countries expertise. The participants were initially invited quite informally to engage and share their experiences in terms of system thinking, and how to respond to the pandemic, in an attempt to promote learning across countries.

The Community of Practice (CoP) was formally launched in June 2020. After the initial technical discussions around approaches and tools, the CoP consolidated its focus on the exchange of experiences across countries. It was also through the use of this platform that brainstorming occurred around how to engage with, and support, district teams within the COVID-19 context. The country institutions discussed their progress and challenges to jointly find solutions for these challenges, noting that some travel within a country context was possible at various points in the timeframe of the pandemic (Figure 2).

The institutions in each country managed to build and establish new relationships with district health managers. District stakeholders were involved in the CoP in an indirect way via the national institutions, and when their agendas and connectivity allowed, they also joined to see how the systems thinking resources and material could provide support. Illustratively, in Pakistan, the identified health system challenge was the strengthening of the COVID-19 contact tracing strategy in Islamabad (see also the case study below, while in Rajanpur, Pakistan, Botswana and Timor-Leste it was the coordination mechanisms at the district level and the strengthening of the district health information system).

A repository of the systems thinking tools is now publically available, with their application shown in Figure 3 below, and all accessed here: Systems Thinking Tools (swisstph.ch)

Resilient health systems require a Systems Thinking approach

Health systems around the world were caught unprepared for the COVID-19 pandemic. In particular, these systems were revealed to operate in under-financed, siloed sub-systems. As a result, they lacked the resilience to adapt to the emerging crisis, and even the tools to understand the situation in time. The existing silos challenged timely coordination and communication between key stakeholders, including communities. They laid bare inefficiencies, brought many services to a halt, and overwhelmed health workers trying to respond to very high numbers of acute cases without the necessary protection or resources.

Ideally, health systems should be able to absorb and adapt to external shocks and emergencies to maintain essential services, while also generating and using data to inform decisions and make changes. Resilience has been described as “the capacity of a system to absorb disturbance and reorganize while undergoing change to still retain essentially the same function, structure, identity, and feedback”. (Walker, B. et al. 2004)

Ideally, health systems should be able to absorb and adapt to external shocks and emergencies to maintain essential services, while also generating and using data to inform decisions and make changes.

In our experience, achieving resilient health systems is tightly linked with the application of systems thinking approaches. The learnings from the ST-DHS initiative during the COVID-19 pandemic highlight that even in resource-poor settings, systems thinking tools and approaches can be beneficial for district health systems. Applying a systems thinking lens can help health system managers gain an overview of the source of problems, be more confident in proposing solutions, while also monitoring and reflecting on the changes, and being able to course-correct as and whenneeded.

Reference

• Walker, B., C. S. Holling, S. R. Carpenter, and A. Kinzig. 2004. Resilience, adaptability and transformability in social–ecological systems. Ecology and Society 9(2): 5. [online] URL: http://www.ecologyandsociety.org/vol9/iss2/art5/