health system dynamics

Health System dynamics

Peter S. Hovmand, PhD, MSWFounding Director, Social System Design Lab

Washington University in St. Louis

7th EUSPR Conference October 31‐November 2, 2016| Berlin, Germany

What makes it difficult for these kids to get the health and mental services they need?

From: https://aeon.co/essays/the‐grim‐intensity‐of‐a‐childhood‐on‐the‐street

What makes it difficult for these kids to get the health and mental services they need?

From: https://aeon.co/essays/the‐grim‐intensity‐of‐a‐childhood‐on‐the‐street

• Environmental shocks• Discrimination• Exclusion from classroom• Poverty• Homelessness and unstable

housing• Undernutrition• Crime• Child abuse and neglect• Domestic violence, sexual assault,

and sexual exploitation • Drug use• Mental illness• Infectious diseases • Chronic diseases

“Reality”Complex social systems and

wicked problems

Perception

Action

Mental modelsPolicycycle

Revisiting the policy cycle

Image of mandala from https://commons.wikimedia.org/wiki/File:Chenrezing_Mandala.svg

Linear cause‐effect thinking versus feedback thinking

Linear cause‐effect thinking

Proportionusing MCP

Women's healthstatus

Access torepdocutive health

services

Quality of supply

Accessibility toinstitutional delivery

Maternal deaths


Linear cause‐effect thinking

Maternal deaths

Proportion ofpregnancies at riskProportion

using MCP

-

Preganancies

+

Spacing

+

-

+

Live births

+

Average women'shealth status

-

Women ofreproductive

age Girls+

+

+

-

-

R1

B1

B2

Feedback thinking

Proportionusing MCP



services

Quality of supply


Maternal deaths


Linear cause‐effect thinking Feedback thinking

Maternal deaths


using MCP

-

Preganancies

+

Spacing

+

-

+

Live births

+

Average women'shealth status

-


age Girls+

+

+

-

-

R1

B1

B2

Proportionusing MCP



services

Quality of supply


Maternal deaths

Ignoring feedback effects in prevention

Some consequences of ignoring feedback in complex social systems • Focusing efforts on low

leverage solutions

• Unintended consequences

• Limited accessibility, acceptability, and utilization of programs

• Not reaching people with greatest need

• Policy resistance, shifting the burden, and victim blaming


wicked problems

Perception

Action


Pictures

Informal causal maps

Mathematical simulation models

Mental models

There is a system

The components of a system

How the components are related through feedback

How people might think about a system

Where one could intervene

What is transformation

What is the generic structure

What are the implications of accumulations and nonlinear relationships

What systems can generate the dynamic behavior

Where are the leverage points

When do boundary conditions determine behavior

Why do things happen

Levels of system insightsDe

ep sy

stem

insig

hts

Surface system

insig

hts

Implicit models Explicit models


wicked problems

Perception

Action


Revisiting the policy cycle

Image of mandala from https://commons.wikimedia.org/wiki/File:Chenrezing_Mandala.svg

Skills ofDeliveryTeams Changes in Skills of

Delivery Team+Learning Rate

Max Skills

+

+ProgramResources

ProgramDevelopment

Cost per ProgramDeveloped

-

Initial Skills ofDelivery Teams

ProgramDevelopment

Budget

+

Proportion ofProgram Changes

+-

Initial ProgramResources

-

Delivery TeamsHiring of

Delivery Teams

Initial DeliveryTeams

Proportion ofChange in Delivery

Teams

- +

-

Delivery TeamStaffing Gap

+-

Staffing GapAdj Time

+

Programs

+

Outcomes -

Quality +

+

PerformanceGoal

PerformanceGap

- +

+

Data Systemsand Processes

Data SystemsDevelopment


Budget

+

MeasuredOutcomes on

Health

+

+

-

Budget

Net Change inBudget

+

+

Cost per DataSystem Change

-

<Max Skills>Initial DataSystems

Time to MeasureOutcomes

Time to MeasurePerformance

-

Data Systemsper Program

Data SystemsNeeded

+

-

<Data Systems Needed>

Fraction of BudgetAllocated to Program

Development

+

Fraction of BudgetAllocated to Data

Systems

Fraction of BudgetAllocated to Programs

+

-

Obsolescence

+

Program Budget+

+

+

Efficacy

Budget AT

Effect of Data Systemson OutcomesMeasurement

Effect of DataSystems on

Performance Gap

Cost per Program

Staff per Program

<Programs>

+

Revenue perOutcome

-

Partnerships

PartnershipDevelopment

Selectivity ofPartners

+

+

+

-

PartnershipDevelopment Adj

Time

Initial Budget

+

Revenue

+

+

<Staff perProgram>

-Implementation+

Skills ofDeliveryTeams Changes in Skills of

Delivery Team+Learning Rate

Max Skills

+

+ProgramResources

ProgramDevelopment

Cost per ProgramDeveloped

-

Initial Skills ofDelivery Teams

ProgramDevelopment

Budget

+

Proportion ofProgram Changes

+-

Initial ProgramResources

-

Delivery TeamsHiring of

Delivery Teams

Initial DeliveryTeams

Proportion ofChange in Delivery

Teams

- +

-

Delivery TeamStaffing Gap

+-

Staffing GapAdj Time

+

Programs

+

Outcomes -

Quality +

+

PerformanceGoal

PerformanceGap

- +

+

Data Systemsand Processes



Budget

+

MeasuredOutcomes on

Health

+

+

-

Budget

Net Change inBudget

+

+

Cost per DataSystem Change

-

<Max Skills>Initial DataSystems

Time to MeasureOutcomes

Time to MeasurePerformance

-

Data Systemsper Program

Data SystemsNeeded

+

-

<Data Systems Needed>

Fraction of BudgetAllocated to Program

Development

+

Fraction of BudgetAllocated to Data

Systems

Fraction of BudgetAllocated to Programs

+

-

Obsolescence

+

Program Budget+

+

+

Efficacy

Budget AT

Effect of Data Systemson OutcomesMeasurement

Effect of DataSystems on

Performance Gap

Cost per Program

Staff per Program

<Programs>

+

Revenue perOutcome

-

Partnerships

PartnershipDevelopment

Selectivity ofPartners

+

+

+

-

PartnershipDevelopment Adj

Time

Initial Budget

+

Revenue

+

+

<Staff perProgram>

-Implementation+

Modelingcycle

• System dynamics is the use of informal maps and formal models with computer simulation to uncover and understand endogenous sources of system behavior (Richardson, 2011, p. 241)

15

System Dynamics

Richardson, G.P. (2011). Reflections on the foundations of system dynamics. System Dynamics Review, 27(3), 219‐243.


16

System Dynamics


Figure 2: stock and flow diagramFigure 1: causal loop diagram


17

System Dynamics


0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Best caseID and PPC QI+, ID Aff. and PPC Acc.

All QI+ID and PPC QI+

ID QI+All QIID QI

PNC QI+All Aff. and Acc.

ANC QI+PPC QI

MCP QI+MCP QIANC QI

Base case

MMR NMR

Maternal deaths


using MCP

-

Preganancies

+

Spacing

+

-

+

Live births

+

Probability ofneonatal

death

Neonataldeaths

+

+

+

Averageneonatal

health status-Average women'shealth status

-


age Girls+

+

+

- MaternalMortality

Ratio

NeonatalMortatlity

Rate+

-

-

+-

Proportionusing service

Gettingservice

+

Qualitysupply ofservice

+

Ratio of supplyto demand

+

Acceptability

AccessibilityAffordabilityof service

+

+

Seekingservice

+

++

+

+

+

Averagequality

+

+

Performance

+

+Observed

performance

Performancegap

+

+

+

+

+

+

+-

-

-

-

-

+

-

R1

B1

B2

B3

B4

R2

R3

B5

B6

-

R4R5

R6R7

Link to ISEE Exchange version

• Participatory method for involving actors in the process of building and using system dynamics models (e.g., Richardson and Andersen, 1995; Vennix, 1996)

• Emphasis in community based system dynamics on building capacity in communities to use models to understand and change systems

Group Model Building

Why engage communities with systems approaches in the first place?

Social determinants of influenced by broader inequities

Systems of oppressions are complex adaptive systems

Improving quality of research• Correcting for bias• Addressing inherent problem of

indeterminacy in system specification

Building capacity for systems change and “dignity of risk”

Improving design of policies and programs to address social and health inequities

Barnes‐Jewish Children’s Hospital

Working with providers

Working with communities

Meaning

Techno

logy

Radical change

Incrementalchange

Incrementalchange

Radical change

Market pull (user‐

centered)

Design driven

Technology push

Using community based system dynamics to support design driven innovation

Adapted from Verganti (2009). Design‐Driven Innovation. Cambridge, MA: Harvard Press

Raising St. Louis Community Design Workshop #1Wohl Community Center July 9, 2013

Raising St. Louis Community Design Workshop #2Wohl Community Center July 30, 2013

Raising St. Louis Community Design Workshop #3Wohl Community Center August 8, 2013

Mental stability• Patience skills• Communication skills• Life‐long learners, continuing education

• Role switching• Classes and education on ways to relieve stress

• Building self‐esteem with parents

• Outreach for developing child as a leader

• Bonding events• Education on setting boundaries with parents

• Counseling sessions (family, couples, individual)

• Spiritual support• Child feeling safety• Sensitivity training with men

Where this work has been happening

Lancet Commission on Obesity• Global increase in obesity is ‘the canary in the

coalmine’ of deeper problems within the societal systems which are driving overconsumption in general, denigrating environments, and creating inequalities and societal problems

• Transdisciplinary and translational

• Taking a systems approach including group model building and formal modeling with computer simulation to:

• Identify common drivers of obesity, undernutrition and climate change

• Stimulate action and strengthen accountability systems

Some closing observations about methods…Engaging communities is an intervention with valued tangible and intangible benefits

“Structural empathy” – having and knowing others understand the structural complexity of a situation

Identifying and sharing knowledge

Complexity a fact of life, having tools makes it more manageable

Believing people can learn how to model and use models

Question Answer

What is the problem? Is the problem dynamic?

Drawing a reference mode with the desired and feared behavior over time over a defined period of time

What kind of problem is it? Primary diagnosis as a learning, coordination, analysis, or restructuring problem

Does the system involve feedbackmechanisms?

Drawing a diagram of the system that involves one or more feedback loops

What kinds of insights would help solve the problem?

Identifying the types of model based insights such as visualizing the system or identifying leverage points that will help solve the problem

What is the purpose of the model? Write a model project description that defines the problem, explains why it is dynamic and involves feedback, and clearly states the purpose in terms of the type of insights that will help solve the problem.

Thank you!

health system dynamics

Documents