systems tools for c h s a g c l diagrams - who · systems tools for complex health systems: a guide...

SYSTEMS TOOLS FOR

COMPLEX HEALTH

SYSTEMS:

A GUIDE TO CREATING

CAUSAL LOOP DIAGRAMS

1. An introduction to Systems Thinking

2. Developing a Rich Picture

3. Creating Interrelationship Digraphs

4. Surfacing Causal Loop Diagrams

5. Applying Systems Thinking Tools

Five sessions

Session One 2

SESSION ONE

INTRODUCTION TO

SYSTEMS THINKING

1. An introduction to Systems Thinking

2. Developing a Rich Picture

3. Creating Interrelationship Digraphs

4. Surfacing Causal Loop Diagrams

5. Applying Systems Thinking Tools

Five sessions

Session One 4

• The complexity of health systems

• Thinking about “systems”

• What is systems thinking?

• How can systems thinking help us address health

system challenges?

• Introducing systems thinking tools

Session outline

Session One 5





system challenges?


Session One 6

Session outline

• What is our current reality?

• How has this changed over time?

Working in health systems...

Session One 7

Current reality for health systems

“practitioners”

Prior context

• Discipline-based expertise (e.g., epidemiology)

• Disease-focused initiatives

• Disease-focused teams and units

• Donors/agencies working in parallel

• Donor-driven programs

Current context

• Focus on Health system strengthening

• Inter- and multi-disciplinary teamwork

• Collaborative partnerships and joint planning

• Complex flows of funding, information and communication channels

• Increased use of technology

• Country-owned sustainable national health strategies

Session One 8

Events and

Symptoms

Patterns

Systems

and Structure

Crises

Tasks

Trends

Reward

Systems

Unwritten Rules

Political dynamics

Hargreaves M, 2010

What is happening now?

How do patterns play out

over time and space?

What are the drivers

and deep structures?

How are they related?

Session One 9

How do we understand our

reality?

Events and

Symptoms

Patterns

Systems

and Structure

Crises

Tasks

Trends

Reward

Systems

Unwritten Rules

Political dynamics

Session One 10

Hargreaves M, 2010

Fire-fighting

Anticipating

Designing

How do we respond to our

reality?





system challenges?


Session outline

Session One 11

Elements of a system

Components/

Variables

Inter-connections

Function

Session One 12

• System: an assembly of components connected

together in an organized way

– Components are affected by being in the system and are

changed if they leave it

• Assembly of components does something

–Assembly has been identified by someone as being

of interest

What is a system?

Session One 13

The central concept “system” embodies the

idea of a set of elements connected together

which form a whole, this showing properties

which are properties of the whole, rather

than properties of its component parts.

(Checkland, 1981)

What is a system?

“

”

Session One 14

• A system is more than the sum of its parts.

• How a system behaves and performs is determined

by its components, the relationships amongst these

components and resultant structure of the system.

• System behavior reveals itself as a series of events

over time.

Thinking about systems

Session One 15

Distinguish between systems based on:

• degree of certainty about the link between cause and effect amongst variables in the system

and

• degree of agreement as to the best course of action

in a situation in order to produce a consistent outcome


Session One 16

http://www.replacementcarkeys.net/


Mills A, 2010

High

High

Low

Low

Degree of certainty

Deg

ree

of a

gree

men

t

Complex systems

Random systems

Simple systems

Session One 17

• Simple (puzzle)

• Complicated (problem)

• Complex (mess)

General types of systems

Session One 18

Following a recipe

• The recipe is essential

• Recipes are tested to assure

replicability of later efforts

• No particular expertise required;

knowing how to cook increases

success

• Recipe notes the quantity and

nature of “parts” needed

• Recipes produce standard

products

• Certainty of same results every

time

Simple (puzzle) systems

Freedman, 2008.

Session One 19

Sending a rocket to the moon

• Formulae are critical and necessary

• Sending one rocket increases

assurance that next will be ok

• High level of expertise in many

specialized fields + coordination

• Separate into parts and then

coordinate

• Rockets similar in critical ways

• High degree of certainty of outcome

Complicated (problem)

systems

Freedman, 2008. Session One 20

Raising a Child

• Formulae have only a limited application

• Raising one child gives no assurance of success with the next

• Expertise can help but is not sufficient - relationships are key

• Can’t separate parts from the whole

• Every child is unique

• Uncertainty of outcome remains

Complex (mess) systems

Freedman, 2008. Session One 21

• Collaborating with partners?

• Implementing a supply chain system?

• Strengthening adherence to anti- retrovirals?

Simple, complicated or

complex?

Session One 22

A complex adaptive system is a collection of

individual actors with freedom to act in

ways that are often not predictable, and

whose actions are interconnected, so that

one agent's actions changes the context for

other agents

(Plesk 2001)

What is a Complex Adaptive

System?

“

”

Session One 23

Observance of health systems – including findings from

failed interventions – tells us that a health system is a

complex adaptive system

BUT

Methods for addressing health system problems are

designed as though the health system is merely

complicated

Health systems are complex

systems

Session One 24





system challenges?


Session outline

Session One 25

Systems thinking is a discipline for seeing

wholes, recognizing patterns and

interrelationships, and learning how to

structure those interrelationships in more

effective, efficient ways.

(Senge & Lannon-Kim 1991)

What is systems thinking?

“

”

Session One 26

It is a way of thinking in approaching problems and in designing solutions that appreciates the very nature of complex [adaptive] systems as:

– dynamic, constantly changing,

– governed by history and by feedback,

– where the role and influence of stakeholders and context is critical, and

– where new policies and actions (of different stakeholders) often generate counterintuitive and unpredictable effects, sometimes long after policies have been implemented – policy resistance.


“

” (Adam 2012)

Session One 27

It is a way of thinking in approaching problems and in

designing solutions that …

…allows the identification of solutions that

simultaneously address different problem areas and

leverage improvement throughout the system.


Allen W, 2013 Session One 28

Events and

Symptoms

Patterns

Systems

and Structure

Crises

Tasks

Trends

Reward

Systems

Unwritten Rules

Political dynamics

Systems Thinking moves from

this….

Hargreaves M, 2010







Session One 29

Events and

Symptoms

Patterns

Systems

and Structure

Crises

Tasks

Trends

… to making sense of the

dynamics

Hargreaves M, 2010







Session One 30




• How can systems thinking help us

address health system challenges?


Session outline

Session One 31

Applying systems thinking to health system helps to:

• anticipate synergies

• mitigate negative emergent behaviours, policy resistance

and unintended consequences

when

• designing changes in the health system

• evaluating these interventions

Health systems are complex

systems

Session One 32

Practitioners need to:

• SEE differently

• THINK differently

• ACT differently

How can “Systems Thinking” help

to understand health systems?

Session One 33

SEE differently

Session One 34

From

• Understanding individual health

systems building blocks

To

• Understanding the relationships

amongst building blocks

Expanding our vision of health

systems

World Health Organization. 2007 Session One 35

From:

• Patients

Towards people:

• who are consumers, taxpayers, citizens and co-producers of health

and

• who interact with each other and their environment in complex, adaptive ways


systems

Session One 36

From

• a sole focus on health outcomes

Towards

• emergent properties that serve to strengthen the health system including:

• Equity

• Trust

• Responsiveness

• Social and fair financing protection

• Efficiency


systems

Session One 37

From

• technical interventions

Towards

• understanding implementation within an enabling environment


systems

Session One 38

THINK differently

Session One 39

We cannot solve our

problems with the

same thinking we used

when we created

them.

(Albert Einstein)

Think differently

“

”

Session One 40

Systems thinking is an ordered, methodological

approach to understanding problem situations and

identifying solutions to these problems.

It takes into account both the “forest and the trees”

through a process of synthesis, analysis and inquiry.

Think differently

Edson R, 2008 Session One 41

Without Systems Thinking…

We risk doing the wrong things with greater and

greater efficiency rather than establishing what is the

right thing to be doing.

“It is better to do the right

thing imperfectly than to keep

doing the wrong thing better

and better.”

(Russell Ackoff, 1995) Session One 42

Think differently

Without Systems Thinking…

We are at risk of committing a Type III Error - the

right answer for the wrong question

(Schwartz 1999)

Think differently

In other words we have the perfect solution for

a problem that has not been adequately

understood

Session One 43

ACT differently

Session One 44

We need new ways of thinking and of working

in order to accommodate the complexity of

the challenges in and urgent need for health

system innovation and change.

(Herbert and Best, 2011)

Act differently

”

Adam T, 2012 Session One 45

“

Accept that systems thinking is about dealing

with the inevitable lack of

comprehensiveness, and is not the means to

achieve comprehensiveness

Act differently

Midgley G, 2007

“

”

(Midgley & Richardson, 2007)

Session One 46

We need systems thinking tools that will assist us to:

• Challenge assumptions

• Make sense of the complexity

• Model a situation over time

• Identify appropriate leverage points for intervention

• Mitigate policy resistance

• Enable collaboration and sharing

Act differently

Session One 47

Systems thinking tools enable three functions:

Synthesis: putting together, assessing the system as a whole in

its environment/context e.g., Rich Picture, Interrelationship Digraph

Analysis: (combined with synthesis) – understanding the detail

and how the components fit together within a context e.g.

Systems Map, Causal Loop Diagrams

Inquiry: developing robust interventions through a systemic

investigation e.g. Systems Dynamic Modeling, Scenario Planning

Act differently

Session One 48

Synthesis

• Understand Whole System Context

• Determine Boundaries

Analysis • Understand System

Itself within Context

• Surface & Challenge Assumptions

Inquiry • Identify Leverage

Points

• Develop Interventions through

Systemic

Investigation

Systems thinking tools

Session One 49





system challenges?

• Introducing (a few) systems thinking

tools

Session Outline

Session One 50

• Rich Pictures

• Inter-relationship diagraphs

• Systems maps (causal loop diagrams)

• Systems dynamic modeling

• Agent based modeling

• Network analysis

• Scenario development

Useful systems thinking tools

Session One 51

Create and use our own causal loop diagrams

What we will do

To end up here… Session One 52

• Define the boundaries of our system – seek to

understand the big picture

• Identify the elements/variables in our system

• Understand how these variables might change over

time

• Surface and test our assumptions (consider how our

mental models affect our understanding of the

current reality)

To do all of the above we develop a RICH PICTURE

We need to first

Session One 53

Session One 54

Rich picture

• Explore how these elements/variables relate to one

another

• Resist coming to a quick conclusion and once again

surface and test our assumptions

• Identify the major drivers and outcomes in our

system

To do this we develop an INTERRELATIONSHIP

DIGRAPH

Then we will

Session One 55

Interrelationship Digraph

Prioritization of(Maternal) Health in

Domestic Policy

Amount of International

FundingGovernment Financial

Resources

Level of Corruption

Presence of Conflict

Level of Infrastructure

Level of Function of

Referral System

Time Until Effective

Care (Third Delay)

Availability of MedicalEquipment, Supplies &

DrugsSize of Health

Workforce

Quality of Health

Services

Session One 56

… do we surface a CAUSAL LOOP DIAGRAM

• Informed by our Rich Picture, Interrelationship

Digraphs

• Considering both short and long-term consequences

• Understanding the system structure to identify

possible leverage actions

And only then…

Session One 57

• Understand the system structure giving rise to the

system behavior

• Find where unintended consequences (policy

resistance) emerge

• Explore consequences of proposed action

• Recognize impact of time delays when exploring

relationships

• Identify possible leverage

points for actions

We use this causal loop

diagram to:

Session One 58

All models are wrong, some are useful

Always remembering that

“ ”

(Attributed to George Box)

Session One 59

• Hargreaves M, Parsons B, and Moore M. “Evaluating Complex Systems Initiatives.” Professional development workshop presented for the National Institutes of Health Evaluation Set-Aside Program, Evaluation Office, Division of Program Coordination, Planning and Strategic Initiatives, Bethesda, MD, February 25–26, 2010.

• Checkland P. (1981). Systems Thinking Systems Practice. Chichester: John Wiley.

• Mills A. Complexity science. An Introduction (and invitation) for actuaries. Society of Actuaries. 2010.

• Freedman, ODI presentation, Exploring the science and remains. complexity of aid policy and practice, London, July 2008.

• Plsek P, Greenhalgh T. Complexity science. The challenge of complexity in health care. BMJ. 2001;323:625–8.

• Senge P, Lannon-Kim C. The Systems Thinker Newsletter. 1991; 2(5).

• Adam T, de Savigny D. Systems thinking for strengthening health systems in LMICs: need for a paradigm shift Health Policy and Planning 2012;27:iv1–iv3

• Allen W. sparksforchange. Complicated or complex – knowing the difference is important. March 3, 2013. http://learningforsustainability.net/sparksforchange/complicated-or-complex-knowing-the-difference-is-important-for-the-management-of-adaptive-systems/

• World Health Organization. Everybody’s Business: Strengthening health systems to improve health outcomes—WHO’s Framework for Action. Geneva: WHO, 2007, page 3.

• Edson R. Systems Thinking. Applied. A Primer. 2008. Accessed December 2014 http://www.anser.org/docs/systems_thinking_applied.pdf

• Midgley G, Richardson KA (ed.) Systems Thinking for Community Involvement in Policy Analysis Systems thinking for community involvement in policy analysis E:CO Issue Vol. 9 Nos. 1-2 2007 pp. 167-183

• Foresight – Tackling obesities: future choices https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/296290/obesity-map-full-hi-res.pdf

References

Session One 60

http://learningforsustainability.net/sparksforchange/complicated-or-complex-knowing-the-difference-is-important-for-the-management-of-adaptive-systems/




























http://www.anser.org/docs/systems_thinking_applied.pdf

http://www.anser.org/docs/systems_thinking_applied.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/296290/obesity-map-full-hi-res.pdf










This work was coordinated by the Alliance for Health Policy and Systems Research,

the World Health Organization, with the aid of a grant from the

International Development Research Centre, Ottawa, Canada.

Thank you

Presentation developed by Helen de Pinho MBBCh, MBA, FCPH

assisted by Anna M. Larsen BS, MPH

Averting Maternal Death and Disability Program (AMDD)

Heilbrunn Department of Population and Family Health

Mailman School of Public Health

Columbia University

February 2015

February 2015

Session One 61

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