Systems thinking is an approach to problem-solving that views problems as part of a wider dynamic system. It recognizes and prioritizes the understanding of linkages, relationships, interactions and interdependencies among the components of a system that give rise to the system’s observed behaviour. Systems thinking is a philosophical frame, and it can also be considered a method with its own tools. 

Why is systems thinking important in HPSR? 

Systems thinking is an approach with a long history that has been applied in different fields, such as computer science, management, and ecology. It has been applied more recently in health policy and systems research (HPSR). Systems thinking takes into consideration that action or changes in one aspect of a health system is likely to affect what results in another. Systems thinking is important in HPSR to navigate the complexity of health systems and to better understand the systems-wide effects, positive and negative, planned and unintended consequences of different interventions, policies, and behaviours. It allows for a more adaptive implementation of health system policies and programmes. 

The Alliance’s track record on systems thinking 

In 2009, the Alliance published its third flagship report, Systems Thinking for Health Systems Strengthening. Responding to the needs of stakeholders around the world, this report introduced ways to forecast how health systems respond to strengthening interventions. In addition, it showed how better evaluations of health system strengthening initiatives can yield valuable lessons. It stimulated and legitimized new thinking on persistent problems for health system stewards, policy-makers, programme implementers, researchers and development partners. The Alliance viewed this report as the beginning of a new stream of work: to support the application of these concepts in real-life settings. 

In 2012, the Alliance sponsored a special supplement of Health Policy and Planning. Until this point, use of systems thinking in HPSR had been practised predominantly in high-income countries. The supplement captured the application of systems thinking in low- and middle-income Countries (LMICs) and provided further guidance on its application in these settings. 

In 2014, another supplement in Health Research Policy and Systems gathered thinking on the development and application of systems thinking methods and approaches, showcasing new research led by LMIC authors. The supplement included papers on system dynamics modelling, causal loop diagrams, social network analysis and pieces that explored how methods such as realist evaluation could be launching pads for systems thinking approaches.

Issue in practice

Promoting the use of systems thinking has remained a key pillar of Alliance efforts. While appreciation for systems thinking in health systems strengthening has increased over time, there is still progress to be made in building the art and science of systems thinking within HPSR. This includes defining and measuring systems thinking impacts, as well as strengthening capacities to undertake systems thinking. The Alliance is working with district health teams, national governments, WHO programmes and researchers to generate evidence on applied systems thinking. The Alliance is also supporting the adoption and adaptation of systems thinking tools and the development of a global community of practice. 

Advancing the use of systems thinking in practice has been central to the Alliance’s approach. The Systems Thinking for Strengthening District Health Systems (ST-DHS) initiative is running in partnership with the Swiss Tropical and Public Health Institute in Botswana, Timor-Leste and Pakistan. Its aim is to make systems thinking routine in the practice of district health managers. To that end, it prioritizes capacity development in methods, data analysis and reflective practice. The hope is that the processes being introduced into district health systems will be integrated into day-to-day practice and successfully sustained over time. ST-DHS is monitoring and evaluating whether this is the case.

The Alliance is also developing a Systems Thinking Accelerator as a way to support a global community of practice on systems thinking. The Accelerator aims to increase the field of applied systems thinking in LMICs and provide a platform for exchange and advocacy for systems thinking. The Alliance expects that this will create a wider and more inclusive community of system thinkers around the globe, especially from LMICs.

Future commitment

Over the coming years, the Alliance will seek to catalyse and support greater work in systems thinking. Ensuring greater donor and national-level investments in this area of work and supporting decision-makers to apply the approach at the government level will be key priorities.

Key resources