Engaging with complexity to improve the health of indigenous people: a call for the use of systems thinking to tackle health inequity

Abstract

The 400 million indigenous people worldwide represent a wealth of linguistic and cultural diversity, as well as traditional knowledge and sustainable practices that are invaluable resources for human development. However, indigenous people remain on the margins of society in high, middle and low-income countries, and they bear a disproportionate burden of poverty, disease, and mortality compared to the general population. These inequalities have persisted, and in some countries have even worsened, despite the overall improvements in health indicators in relation to the 15-year push to meet the Millennium Development Goals. As we enter the Sustainable Development Goals (SDGs) era, there is growing consensus that efforts to achieve Universal Health Coverage (UHC) and promote sustainable development should be guided by the moral imperative to improve equity. To achieve this, we need to move beyond the reductionist tendency to frame indigenous health as a problem of poor health indicators to be solved through targeted service delivery tactics and move towards holistic, integrated approaches that address the causes of inequalities both inside and outside the health sector. To meet the challenge of engaging with the conditions underlying inequalities and promoting transformational change, equity-oriented research and practice in the field of indigenous health requires: engaging power, context-adapted strategies to improve service delivery, and mobilizing networks of collective action. The application of systems thinking approaches offers a pathway for the evolution of equity-oriented research and practice in collaborative, politically informed and mutually enhancing efforts to understand and transform the systems that generate and reproduce inequities in indigenous health. These approaches hold the potential to strengthen practice through the development of more nuanced, context-sensitive strategies for redressing power imbalances, reshaping the service delivery environment and fostering the dynamics of collective action for political reform.

Introduction: Accountability for Health Equity: Galvanising a Movement for Universal Health Coverage

“…Simply calling for 'more accountability' as the means to effect health systems-level change is not enough. However, accountability processes that target the systemic and structural drivers of inequity within health systems have the potential to shape a different future (Lodenstein et al 2013;Hilber et al 2016;Hernández et al 2017), as do those that involve citizens directly as agents of change (Cornwall and Gaventa 2000). In July 2017, the Accountability for Health Equity Programme at IDS brought together engaged intellectuals, innovating activists, and pragmatic problem-solvers in the fields of health systems strengthening and good governance to debate these issues.…”

SDGs, health and the G20: a vision for public policy

“…There is growing evidence for the value of gathering user evidence of the problems community members experience regarding healthcare and services (Hernández et al 2017). There is increased availability of tested digital technology for G20 countries to consider data collection engaging citizens and implement such feedback mechanisms from their citizens and in the lowmiddle income countries they invest in.…”

“…Since then, the concept of primary healthcare has become a core concept of the World Health Organization's (WHO) goal of health for all (Medcalf et al 2015). Engaging communities in decision-making, planning, and implementing programs and policies that are about their own health and well-being leads to citizen empowerment and positive sustainable change (Freire 1970:125;Prost et al 2013;Hernández et al 2017;Gaventa and Barrett 2010). However, this engagement needs to go beyond broad participation of citizen groups, as the inclusion of women and the most vulnerable groups in these processes as key stakeholders and agents of change is crucial in addressing health inequities.…”

“…Citizen knowledge, for example on perceptions of quality of local healthcare services beyond the provision of data on access to services (Grover 2013), is essential if we are to not only focus on achieving health outcomes, but also to understand the mechanisms by which these are achieved. Regular dialogue and relationship building between health system actors and service users are central to addressing tensions, changing mindsets and fostering respectful and culturally appropriate healthcare practices (Hernández et al 2017). …”

Using a ‘rich picture’ to facilitate systems thinking in research coproduction

“…In this way, systems thinking aligns with coproduction's focus on bringing together multiple diverse actors, making coproduction a potential vehicle for systems thinking in-action. Like coproduction, systems thinking has been heralded as a solution to addressing complexity [14,15]; however, like coproduction, it too suffers from a lack of evidence about how to meaningfully apply systems thinking principles in practice [16,17]. To date, literature on systems thinking remains largely theoretical, with comparatively few examples of how to do it in practice to achieve the desired outcomes [17,18].…”