Applied systems thinking: a viable approach to identify leverage points for accelerating progress towards ending neglected tropical diseases

The Neglected Tropical Disease Non-Governmental Organization Network: The role of a global health network in an evolving global health landscape

The Neglected Tropical Diseases NGO Network (NNN) was established in 2009 to bring together non-governmental organizations (NGOs) working towards the control and elimination of neglected tropical diseases (NTDs). In response to the evolving landscape of global health and the increasing focus on equity, the NNN conducted a membership analysis in 2021. This analysis aimed to assess the network's composition and connectivity, revealing significant insights into its current structure and areas for improvement. Key findings from the analysis include the following: a majority of NNN members were based in high-income countries (HICs); 40% of the member organizations concentrated on a single NTD; the African region had nearly twice the number of member organizations supporting interventions in the region compared to other regions; and, members from HICs tend to be better networked within the NNN. These findings highlight the need for the NNN to enhance its inclusivity and representation, ensuring that voices from endemic countries are more prominently integrated into the network. By aligning with the NTD Road Map 2021-2030, the NNN aims to address these disparities and strengthen its commitment to global health equity. This analysis serves as a call to action for other global health networks to undertake similar self-assessments. Through transparency and critical reflection, the pursuit of global health equity can be advanced, ensuring that all regions and diseases receive appropriate attention and resources.

DiScO: novel rapid systems mapping to inform digital transformation of health systems

Background

Global health systems are confronting challenges that intersect climate change with evolving communicable and non-communicable public health risks. Addressing these challenges requires systems integration via citizen big data that exist outside health systems. However, systems integration across jurisdictions is a complex challenge that requires stakeholder input. This study's purpose was to conduct rapid systems mapping with international health system stakeholders to inform the development and implementation of a global digital citizen science observatory (DiScO), which aims to catalyze digital transformation of health systems across jurisdictions.

Methods

A rapid qualitative systems mapping study was conducted during the International Society for Behavioral Nutrition and Physical Activity Annual Global Summit in Uppsala, Sweden, in June 2023. The choice of the venue and approach was informed by three key criteria: (1) Established evidence linking physical activity and nutrition with non-communicable diseases; (2) Concrete existing methods of obtaining citizen big data by physical activity and nutrition researchers; (3) Precedence of physical activity and nutrition researchers conducting citizen science as well behavioral/clinical big data collection. The design of this study was an innovative pre-post systems map development, which consisted of (1) real-time rapid systems mapping (pre/initial map) by engaging with international stakeholders and (2) adjustment of the real-time systems map (post/final map) after analyzing stakeholder discussion data.

Results

Rapid systems mapping resulted in a complex network that included key themes to successfully develop and implement DiScO: priorities, opportunities, risks, challenges, partnerships, and resources. Additionally, a new theme emerged organically through stakeholder group discussions - mitigation strategies. The adapted rapid systems map (i.e., after data analyses) depicts 23 key nodes of intervention across the seven key themes.

Conclusion

Rapid systems mapping at international symposia is a novel methodological approach to capture stakeholder input, particularly to understand complexity across international jurisdictions - an approach that can be replicated across disciplines and sectors to inform digital transformation of health systems. The development and implementation of DiScO, a platform for decentralization and democratization of technology, will take into consideration all the key nodes of intervention identified in the rapid systems map to promote digital health for equity across global jurisdictions.

Building a Systems Map: Applying Systems Thinking to Unhealthy Commodity Industry Influence on Public Health Policy

BACKGROUND

Unhealthy commodity industries (UCIs) engage in political practices to influence public health policy, which poses barriers to protecting and promoting public health. Such influence exhibits characteristics of a complex system. Systems thinking would therefore appear to be a useful lens through which to study this phenomenon, potentially deepening our understanding of how UCI influence are interconnected with one another through their underlying political, economic and social structures. As such this study developed a qualitative systems map to depict the complex pathways through which UCIs influence public health policy and how they are interconnected with underlying structures.

METHODS

Online participatory systems mapping workshops were conducted between November 2021 and February 2022. As a starting point for the workshops, a preliminary systems map was developed based on recent research. Twenty-three online workshops were conducted with 52 geographically diverse stakeholders representing academia, civil society (CS), public office, and global governance organisations (CGO). Analysis of workshop data in NVivo and feedback from participants resulted in a final systems map.

RESULTS

The preliminary systems map consisted of 40 elements across six interdependent themes. The final systems map consisted of 64 elements across five interdependent themes, representing key pathways through which UCIs impact health policy-making: (1) direct access to public sector decision-makers; (2) creation of confusion and doubt about policy decisions; (3) corporate prioritisation of commercial profits and growth; (4) industry leveraging the legal and dispute settlement processes; and (5) industry leveraging policy-making, norms, rules, and processes.

CONCLUSION

UCI influence on public health policy is highly complex, involves interlinked practices, and is not reducible to a single point within the system. Instead, pathways to UCI influence emerge from the complex interactions between disparate national and global political, economic and social structures. These pathways provide numerous avenues for UCIs to influence public health policy, which poses challenges to formulating a singular intervention or limited set of interventions capable of effectively countering such influence. Using participatory methods, we made transparent the interconnections that could help identify interventions in future work.

Complex Interventions for a Complex System? Using Systems Thinking to Explore Ways to Address Unhealthy Commodity Industry Influence on Public Health Policy

BACKGROUND

Interventions are needed to prevent and mitigate unhealthy commodity industry (UCI) influence on public health policy. Whilst literature on interventions is emerging, current conceptualisations remain incomplete as they lack considerations of the wider systemic complexities surrounding UCI influence, which may limit intervention effectiveness. This study applies systems thinking as a theoretical lens to help identify and explore how possible interventions relate to one another in the systems in which they are embedded. Related challenges to addressing UCI influence on policy, and actions to support interventions, were also explored.

METHODS

Online participatory workshops were conducted with stakeholders with expertise in UCIs. A systems map, depicting five pathways to UCI influence, and the Action Scales Model were used to help participants identify interventions and guide discussions. Codebook thematic analysis was used to analyse the data.

RESULTS

Fifty-two stakeholders participated in 23 workshops. Participants identified 27 diverse, interconnected and interdependent interventions corresponding to the systems map's pathways that reduce the ability of UCIs to influence policy. These include, for example, reform policy financing; regulate public-private partnerships (PPPs); reform science governance and funding; frame and reframe the narrative, challenge neoliberalism and gross domestic product (GDP) growth; leverage human rights; change practices on multistakeholder governance; and reform policy consultation and deliberation processes. Participants also identified four potential key challenges to interventions (ie, difficult to implement or achieve; partially formulated; exploited or misused; requires tailoring for context), and four key actions to help support intervention delivery (ie, coordinate and cooperate with stakeholders; invest in civil society; create a social movement; nurture leadership).

CONCLUSION

A systems thinking lens revealed the theoretical interdependence between disparate and heterogenous interventions. This suggests that to be effective, interventions need to align, work collectively, and be applied synchronously to different parts of the system, including multiple levels of governance. Importantly, these interventions need to be supported by intermediary actions to be achieved. Urgent action is now required to strengthen healthy alliances and implement interventions.

Kailo: a systemic approach to addressing the social determinants of young people's mental health and wellbeing at the local level

The mental health and wellbeing of children and young people is deteriorating. It is increasingly recognised that mental health is a systemic issue, with a wide range of contributing and interacting factors. However, the vast majority of attention and resources are focused on the identification and treatment of mental health disorders, with relatively scant attention on the social determinants of mental health and wellbeing and investment in preventative approaches. Furthermore, there is little attention on how the social determinants manifest or may be influenced at the local level, impeding the design of contextually nuanced preventative approaches. This paper describes a major research and design initiative called Kailo that aims to support the design and implementation of local and contextually nuanced preventative strategies to improve children's and young people's mental health and wellbeing. The Kailo Framework involves structured engagement with a wide range of local partners and stakeholders - including young people, community partners, practitioners and local system leaders - to better understand local systemic influences and support programmes of youth-centred and evidence-informed co-design, prototyping and testing. It is hypothesised that integrating different sources of knowledge, experience, insight and evidence will result in better embedded, more sustainable and more impactful strategies that address the social determinants of young people's mental health and wellbeing at the local level.

An analysis of actors participating in the design and implementation of workplace breastfeeding interventions in Mexico using the NetMap analysis approach

Introduction

While breastfeeding is recognized as providing optimal nutrition for infants and toddlers, maternal employment is a commonly mentioned barrier to breastfeeding. The goal was to (a) identify key actors participating in the design and implementation of workplace breastfeeding interventions in Mexico, (b) understand the complexity of interactions between the actors, and (c) map the connections and influence between the actors when looking into networks of Advice, Command, Funding, and Information.

Method

Following the NetMap methodology, a total of 11 semi-structured interviews with 12 interview partners from 10 organizations were conducted. Interview data were analyzed, and networks were analyzed and visualized, using a social network mapping software.

Results

A total of 83 actors from five different actor groups were identified. Four networks were constructed along the four types of connections: Advice, Command, Funding, and Information. The actors were connected by 580 connections with 446 unique links. Based on various network statistics, the Mexican Institute of Social Security, the Mexican Secretary of Labor and Social Welfare, UNICEF, and the Mexican Secretary of Health were identified to be key actors.

Conclusion

To increase the likelihood of success of workplace breastfeeding interventions, the role of the actors "Employers" and "Women" needs to expand. They should be actively involved in the decision-making process, together with the identified key actors. It is further recommended to re-introduce a national breastfeeding strategy for Mexico that includes policies for workplace breastfeeding interventions.

Healthcare Policies to Eliminate Neglected Tropical Diseases (NTDs) in India: A Roadmap

The need for systemic healthcare policies to systematically eliminate NTDs globally and in India has been stressed for more than two decades. Yet, the present policies and the research on them do not meet the need. We present an ontological framework, a research roadmap, and a policy brief to address the gap. The ontology clearly, concisely, and comprehensively represents the combinations of diseases, the objectives regarding the diseases, the entities to address them, the outcomes sought, and the potential policy instruments to invoke. The paper explicates the state of the-policies and state of the research on policies to eliminate NTDs in India. It highlights the significant gaps in the diseases covered, balance in the objectives, comprehensiveness of policies, portfolio of outcomes, and involvement of entities. Last, it presents a set of systemic policies congruent with the ontology to systematically address the gaps. The recommendations are aligned with the present research, policies, practices, and recommendations in India and of the WHO, UN agencies, and other similar bodies. The approach can be generalized to provide roadmaps for other countries facing a similar challenge and for other diseases of similar complexity. The roadmaps, with continuous feedback and learning, can help navigate the challenge efficiently and effectively.

High Level of Knowledge about Tungiasis but Little Translation into Control Practices in Karamoja, Northeastern Uganda

Tungiasis is a neglected tropical disease (NTD) that can cause significant suffering and disability. Health promotion is an important pillar in NTD control programs, assuming that better knowledge contributes to reduced risk behavior and reduced risk of infection. The study objective was to assess tungiasis-related knowledge and its translation into control practices in a rural and highly endemic setting in Karamoja, Northeastern Uganda. We applied a mixed-methods design on household and community level. A semi-quantitative questionnaire on knowledge, practices, and attitudes (KAP) regarding tungiasis was administered to 1329 individuals with the main caring responsibilities in the household. Additionally, eight community dialogue meetings were held and analyzed. Overall, knowledge of tungiasis in humans was high but knowledge of tungiasis in animals was low. Most questionnaire respondents knew the causative agent and clinical presentations of tungiasis in humans, risk factors, and preventive measures. This tungiasis-related knowledge was translated into simple prevention measures. However, adequate tungiasis control was impeded due to a lack of resources, such as access to water and effective medical treatment. In conclusion, health promotion campaigns should be integrated with support towards adequate tungiasis control measures, such as provision of safe treatment, hardening of non-solid floors in the houses, and improved access to water.

Strengthening national public health institutes: a systematic review on institution building in the public sector

Introduction

Strong and efficient institutions are vital to the development of well-functioning governments and strong societies. The term "institution building" encompasses the creation, support, development, and strengthening of organizations and institutions. Still, there is little aggregated evidence on "institution building" considering a wider system-thinking approach, best practices, or development cooperation specifically in the field of public health. In 2007, the International Association of National Public Health Institutes (IANPHI) created a guiding Framework that countries may use for developing National Public Health Institutes (NPHIs). This Framework is currently being revised.

Methods

In this context, we conducted a systematic review to facilitate this revision with recent evidence on institution building and its potential contribution to NPHI. We followed the PRISMA guidelines for systematic reviews, searching for relevant publications in seven scientific databases (Pubmed, VHL/LILACS, EconLit, Google Scholar, Web of Science, World Affairs Online, ECONBIZ) and four libraries (World Bank; European Health for All database of the World Health Organization European Region, WHO; Organization for Economic Cooperation and Development, OECD; and the African Union Common Repository). The search was carried out in October 2021. We used the "framework analysis" tool for systematically processing documents according to key themes.

Results

As a result, we identified 3,015 records, of which we included 62 documents in the final review. This systematic review fills a major gap of aggregated information on institution building in the field of public health and National Public Health Institutes. It is to our knowledge the first systematic review of this kind. The overriding result is the identification and definition of six domains of institution building in the health sector: "governance," "knowledge and innovation," "inter-institutional cooperation," "monitoring and control," "participation," and "sustainability and context-specific adaptability."

Discussion

Our results show that the described domains are highly relevant to the public health sector, and that managers and the scientific community recognize their importance. Still, they are often not applied consistently when creating or developing NPHIs. We conclude that organizations engaged in institution building of NPHIs, including IANPHI, may greatly benefit from state-of-the-art research on institution building as presented in this study.

Development of the Systems Thinking for Health Actions framework: a literature review and a case study

BACKGROUND

Systems thinking is an approach that views systems with a holistic lens, focusing on how components of systems are interconnected. Specifically, the application of systems thinking has proven to be beneficial when applied to health systems. Although there is plenty of theory surrounding systems thinking, there is a gap between the theoretical use of systems thinking and its actual application to tackle health challenges. This study aimed to create a framework to expose systems thinking characteristics in the design and implementation of actions to improve health.

METHODS

A systematised literature review was conducted and a Taxonomy of Systems Thinking Objectives was adapted to develop the new 'Systems Thinking for Health Actions' (STHA) framework. The applicability of the framework was tested using the COVID-19 response in Pakistan as a case study.

RESULTS

The framework identifies six key characteristics of systems thinking: (1) recognising and understanding interconnections and system structure, (2) identifying and understanding feedback, (3) identifying leverage points, (4) understanding dynamic behaviour, (5) using mental models to suggest possible solutions to a problem and (6) creating simulation models to test policies. The STHA framework proved beneficial in identifying systems thinking characteristics in the COVID-19 national health response in Pakistan.

CONCLUSION

The proposed framework can provide support for those aiming to applying systems thinking while developing and implementing health actions. We also envision this framework as a retrospective tool that can help assess if systems thinking was applied in health actions.

Pivoting from systems “thinking” to systems “doing” in health systems—Documenting stakeholder perspectives from Southeast Asia

Applications of systems thinking in the context of Health Policy and Systems Research have been scarce, particularly in Low- and Middle-Income Countries (LMICs). Given the urgent need for addressing implementation challenges, the WHO Alliance for Health Policy and Systems Research, in collaboration with partners across five global regions, recently initiated a global community of practice for applied systems thinking in policy and practice contexts within LMICs. Individual one on one calls were conducted with 56 researchers, practitioners & decision-makers across 9 countries in Southeast Asia to elucidate key barriers and opportunities for applying systems thinking in individual country settings. Consultations presented the potential for collaboration and co-production of knowledge across diverse stakeholders to strengthen opportunities by applying systems thinking tools in practice. While regional nuances warrant further exploration, there is a clear indication that policy documentation relevant to health systems will be instrumental in advancing a shared vision and interest in strengthening capacities for applied systems thinking in health systems across Southeast Asia.

How to do (or not to do)…Using Causal Loop Diagrams for Health System Research in Low- and Middle-Income Settings

Causal loop diagrams (CLDs) are a systems thinking method that can be used to visualize and unpack complex health system behaviour. They can be employed prospectively or retrospectively to identify the mechanisms and consequences of policies or interventions designed to strengthen health systems and inform discussion with policymakers and stakeholders on actions that may alleviate sub-optimal outcomes. Whilst the use of CLDs in health systems research has generally increased, there is still limited use in low- and middle-income settings. In addition to their suitability for evaluating complex systems, CLDs can be developed where opportunities for primary data collection may be limited (such as in humanitarian or conflict settings) and instead be formulated using secondary data, published or grey literature, health surveys/reports and policy documents. The purpose of this paper is to provide a step-by-step guide for designing a health system research study that uses CLDs as their chosen research method, with particular attention to issues of relevance to research in low- and middle-income countries (LMICs). The guidance draws on examples from the LMIC literature and authors’ own experience of using CLDs in this research area. This paper guides researchers in addressing the following four questions in the study design process; (1) What is the scope of this research? (2) What data do I need to collect or source? (3) What is my chosen method for CLD development? (4) How will I validate the CLD? In providing supporting information to readers on avenues for addressing these key design questions, authors hope to promote CLDs for wider use by health system researchers working in LMICs.

Potential Capacity of China's development assistance for health on neglected tropical diseases

Neglected tropical diseases (NTDs) are important health problem in tropical and sub-tropical regions, which afflict more than a billion people worldwide and cause several million deaths every year, especially in Africa. The World Health Organization has called for global efforts to control and eliminate NTDs. China began its health assistance program from 1950s, especially on medical mission dispatched to more than 50 African countries. In this study, a SWOT analysis was used to analyze the current strengths, weaknesses, opportunities, and threats of China's health assistance relating to NTDs, in order to provide the recommendation to promote the activities on international assistance and cooperation on NTDs. Based on this analysis, interventions for NTDs and suggestions for future cooperation relating to NTDs are proposed. In the context of global health, China should strengthen and improve the capacity on health assistance for NTDs control.

Rethinking the Top-Down Approach to Schistosomiasis Control and Elimination in Sub-Saharan Africa

The control and elimination of schistosomiasis have over the last two decades involved several strategies, with the current strategy by the World Health Organization (WHO) focusing mainly on treatment with praziquantel during mass drug administration (MDA). However, the disease context is complex with an interplay of social, economic, political, and cultural factors that may affect achieving the goals of the Neglected Tropical Disease (NTD) 2021-2030 Roadmap. There is a need to revisit the current top-down and reactive approach to schistosomiasis control among sub-Saharan African countries and advocate for a dynamic and diversified approach. This paper highlights the challenges of praziquantel-focused policy for schistosomiasis control and new ways to move from schistosomiasis control to elimination in sub-Saharan Africa. We will also discuss an alternative and diversified approach that consists of a Systems Thinking Framework that embraces intersectoral collaboration fully and includes co-creating locally relevant strategies with affected communities. We propose that achieving the goals for control and elimination of schistosomiasis requires a bottom-up and pro-active approach involving multiple stakeholders. Such a pro-active integrated approach will pave the way for achieving the goals of the NTD 2021-2030 roadmap for schistosomiasis, and ultimately improve the wellbeing of those living in endemic areas.