Advancing the application of systems thinking in health: analysing the contextual and social network factors influencing the use of sustainability indicators in a health system – a comparative study in Nepal and Somaliland

Abstract

BackgroundHealth systems strengthening is becoming a key component of development agendas for low-income countries worldwide. Systems thinking emphasizes the role of diverse stakeholders in designing solutions to system problems, including sustainability. The objective of this paper is to compare the definition and use of sustainability indicators developed through the Sustainability Analysis Process in two rehabilitation sectors, one in Nepal and one in Somaliland, and analyse the contextual factors (including the characteristics of system stakeholder networks) influencing the use of sustainability data.MethodsUsing the Sustainability Analysis Process, participants collectively clarified the boundaries of their respective systems, defined sustainability, and identified sustainability indicators. Baseline indicator data was gathered, where possible, and then researched again 2 years later. As part of the exercise, system stakeholder networks were mapped at baseline and at the 2-year follow-up. We compared stakeholder networks and interrelationships with baseline and 2-year progress toward self-defined sustainability goals. Using in-depth interviews and observations, additional contextual factors affecting the use of sustainability data were identified.ResultsDifferences in the selection of sustainability indicators selected by local stakeholders from Nepal and Somaliland reflected differences in the governance and structure of the present rehabilitation system. At 2 years, differences in the structure of social networks were more marked. In Nepal, the system stakeholder network had become more dense and decentralized. Financial support by an international organization facilitated advancement toward self-identified sustainability goals. In Somaliland, the small, centralised stakeholder network suffered a critical rupture between the system’s two main information brokers due to competing priorities and withdrawal of international support to one of these. Progress toward self-defined sustainability was nil.ConclusionsThe structure of the rehabilitation system stakeholder network characteristics in Nepal and Somaliland evolved over time and helped understand the changing nature of relationships between actors and their capacity to work as a system rather than a sum of actors. Creating consensus on a common vision of sustainability requires additional system-level interventions such as identification of and support to stakeholders who promote systems thinking above individual interests.

The Sustainability of Evidence-Based Interventions and Practices in Public Health and Health Care

“…Hybrid trials to assess both program effectiveness and aspects of implementation and sustainability are becoming more common (28, 71). Systems science approaches, network analysis, time series analysis, survival analysis, and other nonlinear methods may also be useful for capturing the complexity of the continuation, discontinuation, and replacement of interventions within complex service settings (12,81,103,111). Experimental designs are not common in sustainability research, and they may be most useful for testing out which strategies are effective in increasing the sustainability of EBIs.…”

Using Concept Mapping to Develop a Human Rights Based Indicator Framework to Assess Country Efforts to Strengthen Rehabilitation Provision and Policy: The Rehabilitation System Diagnosis and Dialogue (RESYST) Framework

“…Health systems have been described as complex adaptive systems [63], meaning that they are constantly changing as they are susceptible to internal and external influences, and are composed of various subsystems. In the context of rehabilitation, it has been argued that decision making teams and service organizations operate in a chaotic environment and thus constitute self-defined, unpredictable subsystems of broader healthcare systems characterized also by complexity and interconnectedness whereby components of these subsystem affect each other [64][65][66]. In our conceptual model, the words in the cluster labels represent inputs, outputs, initial and/or final outcomes but also processes, flows, controls and context across the system strengthening chain and each word triggers a response by the others, such as commitments and priorities, planning and performance, coverage and utilization.…”

Factors Impacting Sustainability of Community Health Worker Programming in rural Uganda: A Qualitative Study

“…Sustainability enablers identified in this study are consistent with the literature. Community ownership of the health interventions because this enables the local stakeholders to own the intervention having contributed to its implementation and the benefits involved (29,30). Working within existing community systems enables sustainability of health interventions since the foundation of the intervention depends on resources generated in the community (31,32).…”

“…Community mobilization and sensitization at all stages of the implementation of the interventions plays a major role in the sustainability of the interventions. Whenever community members are not involved they oppose the interventions and they do not offer support to the CHWs contrary to the feeling of ownership whenever they are involved from the start (30,41). Moreover whenever community members are involved from the start the sense of ownership propels them to support the interventions due to the fact they appreciate the benefits especially when they view themselves as having contributed towards disease prevention in the community (32).…”