Taking Systems Thinking to the Global Level: Using the WHO Building Blocks to Describe and Appraise the Global Health System in Relation to COVID-19

Strengthening primary health care in Ethiopia: A scoping review of successes, challenges, and pathways towards universal health coverage using the WHO monitoring framework

INTRODUCTION

The ultimate goal of primary health care (PHC), as a whole-of-government and whole-of-society approach, is to achieve the highest level of health by bringing health services closer to the users. This entails that PHC should be viewed as the all-inclusive strategy to achieve universal health coverage (UHC) of the sustainable development goals (SDG). Ethiopia has been implementing PHC since the Alma-Ata Declaration. The World Health Organization (WHO) has recently released a PHC Monitoring Framework to support the monitoring of progress in PHC implementation. However, an evidence gap highlights the need for studies investigating PHC progress towards UHC using this progress monitoring framework. This study aims to evaluate Ethiopia's PHC system using the WHO PHC monitoring framework and identify successes and challenges towards UHC and health security.

METHOD

This scoping review was conducted and structured based on Arksey and O'Malley's methodological framework. We searched five databases (PubMed, Scopus, Embase, Web of Science, CINAHL) and hand-searched for relevant articles. We used the WHO PHC monitoring conceptual framework to summarise findings qualitatively. We reported our findings using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) framework.

RESULTS

We included a total of 110 papers - 56 cross-sectional/national surveys, 19 qualitative studies, 16 mixed-method studies, five fiscal/cost/formative or project model analyses, three ecological/ethnographic studies, three longitudinal/quasi-experimental studies, and two each of implementation/participatory research, cohort studies, and case studies. The Ethiopian PHC system has achieved encouraging success in improving healthcare access and coverage, driven by growing political and leadership commitments through implementing a national health extension package (HEP), service integration and multisectoral approaches to achieve UHC. However, Ethiopia's efforts to achieve UHC have faced many challenges, including inadequate service integration, lack of resources and budgets, uneven distribution of health workers and infrastructure, gaps in priority setting, service innovation, stakeholder engagement and funding PHC research. These are affecting access to affordable care and hindering the progress towards UHC.

CONCLUSION

Ethiopia's PHC system has achieved significant progress in expanding infrastructure and improving access to health services towards UHC. However, challenges remain, particularly in underserved rural areas, with inequitable access, weak governance, and limited integration of essential services. Hence, by improving resource allocation, addressing rural inequities, systemic and infrastructural challenges and fostering stronger governance and service integration, Ethiopia can further improve and build on the successes of the PHC system, making it more resilient and better equipped to meet the health needs of its population.

Motivation and experiences of dentists of primary care dental clusters in Hungary: a qualitative inquiry

Background

In recent years, dental clusters and networks have been established in primary care in many countries to improve access to services for the population and develop cooperation between providers. In Hungary, the first dental clusters were established in 2021, and currently, one-third of dental practices have already joined a cluster. The study aimed to gather and analyze early experiences regarding the motivation of participation in primary care dental clusters and experiences of implementation.

Methods

Qualitative in-depth individual interviews with primary care dentists (n = 21). The study was designed to meet the COREQ criteria for reporting qualitative research. The research team members defined a purposive sample of interviewees. All interviews were conducted from March to April 2024. A qualitative content analysis method was used to analyze the interview transcripts. The WHO health system framework was chosen for the theoretical framework of the analysis.

Results

The motivations for joining a dental cluster were financial reasons, professional development and knowledge exchange. Lack of information and distrust were barriers to joining the dental clusters. Different professional management practices have developed within the clusters. In the interviewees' opinion, the population's access to preventive dental services has not yet changed substantially under the new operational model. The portfolio of services offered by dental clusters could be expanded to include a range of types of care. Digital health technologies and innovative solutions should be developed and widely adopted.

Conclusions

In designing policy measures to promote the broader adoption of the dental cluster model, it is helpful to consider the different factors influencing dentists' decisions during implementation. Dental clusters can benefit the public and dentists, but further development of the model and improvement of the primary conditions for the operation of practices are essential.

The politics of health systems policies during COVID-19: reflections on experiences from Latin America and the Caribbean

Politics as the exercise of power always influence public policies-which reflects the multifaceted nature of decision-making-but "using politics" as a motivation for self-serving interests of government leaders and their allies poses problems. This article reviews the impacts of COVID-19 on health systems of the Latin American and Caribbean region from a political lens. We highlight the overriding influence of politics in health policies, weak governance structures that became compromised, exacerbation of corruption, and breakdowns in the communication and trust between governments and their citizens. There are many factors that did not work well-or as expected. For instance, the poor predictive ability of the Global Health Security Index, which showed that pre-pandemic assessments were deeply naive to how health systems evidence and expertise are uniquely vulnerable to politics. We argue that there is an urgent need to rethink health policy and systems frameworks-including metrics-at national and global level. There is also a need for new global health governance arrangements. The expected solidarity and collaboration among countries was trumped by the rich countries practice of gauging essential resources and vaccines and applying health diplomacy to the rest of the world, and the unchecked power of commercial corporations producing essential medical supplies and vaccines.

Leadership's Perceptions of Palliative Care During the COVID-19 Pandemic: A Qualitative Study

CONTEXT

Palliative care (PC) played a leading role in the COVID-19 pandemic. However, little is known regarding health system leadership's perceptions.

BACKGROUND

This study aimed to explore the perceptions, understanding, and utilization of PC before compared to during the COVID-19 pandemic among health system leadership.

METHODS

Semi-structured, in-depth interviews were conducted with leaders in a large healthcare system based in Massachusetts, United States.

RESULTS

A total of 22 in-depth interviews were completed at four facilities. Emerging themes included the role of PC before compared to during the COVID-19 pandemic, facilitators and barriers to PC delivery, and recommendations for future practice. Participants reported that the COVID-19 pandemic increased PC utilization, reinforced positive perceptions of the specialty, and emphasized its role in maximizing healthcare efficiency. Many participants found PC financing to be a barrier to delivery; some had an inaccurate understanding of how PC is reimbursed. When asked about their recommendations for improving future practice, participants noted improvements in coordination within the healthcare system and education of healthcare providers and future physicians in primary PC skills.

CONCLUSIONS

Our findings suggest that healthcare leadership increasingly understands the value of PC and its critical role within the health system and during future public health emergencies; this was further reinforced during the COVID-19 pandemic. Healthcare leadership recognizes and highlights the need to increase investments in this specialty, both financially and educationally. In doing so, healthcare costs will be lowered, patient satisfaction will increase, and care will be better coordinated.

Using Systems Thinking and Complexity Theory to understand and improve Emergency Medicine: Lessons from COVID-19 in a safety net health system

RATIONALE

COVID-19 has fundamentally changed the practice of Emergency Medicine (EM). Care delivery on the front lines has historically depended upon ostensibly reliable input-output models for staffing, supplies, policies, and therapies. Challenged by the complexity of healthcare during the pandemic, the fallibility of these reductionist models was quickly revealed. Providers and systems quickly had to reconceptualize their dependence on the wider, complex system in which healthcare operates and find adaptive solutions to rapid changes.

AIMS/METHOD

This papers seeks to review and describe how Systems Thinking and Complexity Theory (ST/CT)-concepts, principles, and tools that can be used to understand and impact our constantly evolving health system-can be applied to better understand and enact change in complex settings such as during COVID-19. Some of these ST/CT are described through the real world example of the Alameda Health System Vaccine Taskforce.

RESULTS

ST/CT concepts such as Unintended Consequences, Interrelationships, Emergent Behavior, Feedback Loops, and Path Dependence can help EM providers and planners understand the context in which their system operates. Key principles such as Collaboration, Iterative Learning, and Transformational Leadership can help these actors respond to current and future challenges. The integration of these concepts and principles into the Learning Health System offers a model for tying these key concepts and principles together into an adaptive, cross-sectoral organizational approach.

CONCLUSION

By integrating ST/CT into the practice of EM, we can not only improve our ability to care for patients but also our capacity to understand and strengthen our wider systems of care.

Health systems resilience in fragile and conflict-affected settings: a systematic scoping review

BACKGROUND

Health systems resilience (HSR) research is a rapidly expanding field, in which key concepts are discussed and theoretical frameworks are emerging with vibrant debate. Fragile and conflict-affected settings (FCAS) are contexts exposed to compounding stressors, for which resilience is an important characteristic. However, only limited evidence has been generated in such settings. We conducted a scoping review to: (a) identify the conceptual frameworks of HSR used in the analysis of shocks and stressors in FCAS; (b) describe the representation of different actors involved in health care governance and service provision in these settings; and (c) identify health systems operations as they relate to absorption, adaptation, and transformation in FCAS.

METHODS

We used standard, extensive search methods. The search captured studies published between 2006 and January 2022. We included all peer reviewed and grey literature that adopted a HSR lens in the analysis of health responses to crises. Thematic analysis using both inductive and deductive approaches was conducted, adopting frameworks related to resilience characteristics identified by Kruk et al., and the resilience capacities described by Blanchet et al. RESULTS: Thirty-seven studies met our inclusion criteria. The governance-centred, capacity-oriented framework for HSR emerged as the most frequently used lens of analysis to describe the health responses to conflict and chronic violence specifically. Most studies focused on public health systems' resilience analysis, while the private health sector is only examined in complementarity with the former. Communities are minimally represented, despite their widely acknowledged role in supporting HSR. The documentation of operations enacting HSR in FCAS is focused on absorption and adaptation, while transformation is seldom described. Absorptive, adaptive, and transformative interventions are described across seven different domains: safety and security, society, health system governance, stocks and supplies, built environment, health care workforce, and health care services.

CONCLUSIONS

Our review findings suggest that the governance-centred framework can be useful to better understand HSR in FCAS. Future HSR research should document adaptive and transformative strategies that advance HSR, particularly in relation to actions intended to promote the safety and security of health systems, the built environment for health, and the adoption of a social justice lens.

Implementing recommended breastfeeding practices in healthcare facilities in India during the COVID-19 pandemic: a scoping review of health system bottlenecks and potential solutions

Background

Breastfeeding practices in institutional settings got disrupted during the COVID-19 pandemic. We reviewed the challenges faced and the "work-around" solutions identified for implementing recommended breastfeeding practices in institutionalized mother-newborn dyads in resource constrained settings during the pandemic with the aim to identify learnings that could be potentially adapted to the Indian and relatable contexts, for building resilient health systems.

Methods

We conducted a scoping review of literature using the PRISMA ScR Extension guidelines. We searched the Medline via PubMed and Web of Science databases for literature published between 1st December 2019 and 15th April 2022. We included original research, reviews, and policy recommendations published in English language and on India while others were excluded. Further, we searched for relevant gray literature on Google (free word search), websites of government and major professional bodies in India. Three reviewers independently conducted screening and data extraction and the results were displayed in tabular form. Challenges and potential solutions for breastfeeding were identified and were categorized under one or more suitable headings based on the WHO building blocks for health systems.

Results

We extracted data from 28 papers that were deemed eligible. Challenges were identified across all the six building blocks. Lack of standard guidelines for crisis management, separation of the newborn from the mother immediately after birth, inadequate logistics and resources for infection prevention and control, limited health workforce, extensive use of formula and alternative foods, inconsistent quality of care and breastfeeding support, poor awareness among beneficiaries about breastfeeding practices (and especially, about its safety during the pandemic) were some of the challenges identified. The solutions primarily focused on the development of standard guidelines and operating procedures, restricted use of formula, use of telemedicine services for counseling and awareness and improving resource availability for risk mitigation through strategic mobilization.

Conclusion

The COVID-19 pandemic has provided rich learning opportunities for health system strengthening in India. Countries must strengthen learning mechanisms to identify and adapt best practices from within their health systems and from other relatable settings.

Viewing the global health system as a complex adaptive system - implications for research and practice

The global health system (GHS) is ill-equipped to deal with the increasing number of transnational challenges. The GHS needs reform to enhance global resilience to future risks to health. In this article we argue that the starting point for any reform must be conceptualizing and studying the GHS as a complex adaptive system (CAS) with a large and escalating number of interconnected global health actors that learn and adapt their behaviours in response to each other and changes in their environment. The GHS can be viewed as a multi-scalar, nested health system comprising all national health systems together with the global health architecture, in which behaviours are influenced by cross-scale interactions. However, current methods cannot adequately capture the dynamism or complexity of the GHS or quantify the effects of challenges or potential reform options. We provide an overview of a selection of systems thinking and complexity science methods available to researchers and highlight the numerous policy insights their application could yield.   We also discuss the challenges for researchers of applying these methods and for policy makers of digesting and acting upon them. We encourage application of a CAS approach to GHS research and policy making to help bolster resilience to future risks that transcend national boundaries and system scales.