Advancing the application of systems thinking in health: understanding the dynamics of neonatal mortality in Uganda

Abstract

BackgroundOf the three million newborns that die each year, Uganda ranks fifth highest in neonatal mortality rates, with 43,000 neonatal deaths each year. Despite child survival and safe motherhood programmes towards reducing child mortality, insufficient attention has been given to this critical first month of life. There is urgent need to innovatively employ alternative solutions that take into account the intricate complexities of neonatal health and the health systems. In this paper, we set out to empirically contribute to understanding the causes of the stagnating neonatal mortality by applying a systems thinking approach to explore the dynamics arising from the neonatal health complexity and non-linearity and its interplay with health systems factors, using Uganda as a case study.MethodsLiterature reviews and interviews were conducted in two divisions of Kampala district with high neonatal mortality rates with mothers at antenatal clinics and at home, village health workers, community leaders, healthcare decision and policy makers, and frontline health workers from both public and private health facilities. Data analysis and brainstorming sessions were used to develop causal loop diagrams (CLDs) depicting the causes of neonatal mortality, which were validated by local and international stakeholders.ResultsWe developed two CLDs for demand and supply side issues, depicting the range of factors associated with neonatal mortality such as maternal health, level of awareness of maternal and newborn health, and availability and quality of health services, among others. Further, the reinforcing and balancing feedback loops that resulted from this complexity were also examined. The potential high leverage points include special gender considerations to ensure that girls receive essential education, thereby increasing maternal literacy rates, improved socioeconomic status enabling mothers to keep healthy and utilise health services, improved supervision, and internal audits at the health facilities as well as addressing the gaps in resources (human, logistics, and drugs).ConclusionsSynthesis of theoretical concepts through CLDs facilitated our understanding and interpretation of the interactions and feedback loops that contributed to the stagnant neonatal mortality rates in Uganda, which is the first step towards discussing and exploring the potential strategies and their likely impact.

Alignment between nationally determined contributions and the sustainable development goals for West Africa

“…Finally, we identified the interactions between the NDCs and SDGs by employing causal loop diagrams to show how one variable can interact positively or negatively with another. Causal loop analysis utilises diagrams to map the relationships between multiple variables and represent dynamical changes in systems (Rwashana et al, 2014). In constructing the causal loops, this study employed the Vensim PLE software (Ventana Systems Inc. (2009) Vensim, version 5.9) in a similar fashion described by Sarriot et al (2015).…”

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“…stock and flow diagrams, and causal loop diagrams, respectively), which can be implemented in more or less participatory ways. Building upon earlier work by Rwashana et al [12–14], we use causal loop diagramming as a platform for a more in-depth exploration of trust. By constructing a causal map of both the determinants of trust and how trust affects eventual uptake of services, it becomes possible to see the various pathways in which trust is both developed and lost.…”

“…Not teasing out the various factors that can create feedback and unintended consequences along this path prevents the exploration of other potential factors through which trust can be built and re-built. To date, none of the existing models for immunization or other services [14] have focused on understanding the pathways used to rebuild trust.…”

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