Conceptual Frameworks: Health Systems and the Community

Henry PerryJohns Hopkins University

CORE Group, 30 April 2010

Frameworks are mental models

Tools for Transformational Change to Promote the Production of Health

The Leadership Disciplines*

• Personal Mastery• Mental Models• Systems Thinking• Shared Vision• Team Learning

*Peter Senge, The Fifth Discipline, 1990

Do we actually see reality or just our “mental models”?

“ ‘Mental models’ are deeply ingrained assumptions, generalizations, or even pictures or images that influence how we understand the world and how we take action.”

Peter Senge, The Fifth Discipline, p.8.

Mental Models• Mental models are the lenses through

which we observe reality.

• Our perception of reality is totally dependent upon the amount of distortion in these lenses. But do we accept that we all have these lenses?

Mental Models• Mental models are the structures

that we impose on reality.

• We produce in our minds concepts of reality (paradigms), and these predetermine what we will actually be able to see when we observe reality.

Mental Models by Other Names• Perceptions• World View• Assumptions• Paradigm, Conceptual Framework• Beliefs• Prejudice

How we think determines what we see and how we act.

It’s not “Seeing is believing”, but “Believing is seeing”!

Mental Models Define Our “Reality” and Pre-determine the Choices We Make and the Actions We Take

• Who “produces crops” in your mental model of the agricultural system?– How does your answer determine the roles

and functions of the Ministry of Agriculture?

• Who “produces health” in your mental model of the health system?– How does your answer determine the roles

and functions of the Ministry of Health?

What is a system?

Systems Thinking Looks at:• The whole and the parts

and • The interactions among

the partsStudies the whole in order

to understand the parts

Systems

A system is something that:

•maintains its existence and

•functions as a whole

Through the interaction of its parts.

Households

Government Communities

The Health Production System

The Health System has an inherent stability

Households

Government Communities

ValuesValues

PracticesPractices ResourcesResources

ValuesValues

PracticesPractices ResourcesResources

ValuesValues

PracticesPractices ResourcesResources

Mosley and Chen, 1984

Mosley and Chen 1984

Census-base, Impact-Oriented (CBIO) Conceptual Framework

• Basic assumptions: improving the health of a defined population is the overarching goal

• Strong community-partnerships are required for this, and this trust between the health system and the community, and this requires, among other things, responding to community priorities

CBIO (cont.)

Steps:– Define the community– Make a community diagnosis of epidemiological

priorities and the community’s priorities– Epidemiological priorities: most serious, preventable,

readily preventable or treatable conditions in the community

– Community priorities: no clear framework for defining this

– Clarify program priorities by merging epidemiologial priorities and community priorities

CBIO (cont.)

Steps (cont)- Define resources available (social capital, human resources, money, etc.)- Plan program- Implement program- In 3-5-10 years, carry out community

diagnosis again

Routine systematic home visitation a key action- For defining epidemiological priorities- For defining community priorities- For delivering key services- For monitoring progress and measuring

health improvement

Strengthening Health Systems to Improve Health Outcomes. WHO, 2007

Framework of the Health of the Public

• Disease-oriented public health – Control specific diseases or conditions

• Services-oriented public health– Ensure that those who need services get them

• Community-oriented public health– Work with communities to help them improve their health

• All three are equally important and are like the legs of a three-legged stool

– John Wyon

Primary Health Care: An Ambiguous Mental Model?

• Medical care system delivery concept• Alma Ata concept• Health system model vs. production of health

model (World Health Organization vs World “Disease” Organization)

• Community-based primary health care

IMCI

• Facility-based IMCI

• Community-based IMCI

What Is Health?

Final Challenge

What is the most appropriate mental model

conceptual framework for thinking about how

to achieve a world in which no one dies of a

preventable disease or health-related

condition?