Editorials AliceMaze

Published on October 15th, 2012 | by Dena Javadi


Systems Thinking: Simplicity follows Complexity

A little dose of Wonderland to set the scene:

“Would you tell me, please, which way I ought to go from here?”
“That depends a good deal on where you want to get to,” said the Cat.
“I don’t much care where–” said Alice.
“Then it doesn’t matter which way you go,” said the Cat.
“–so long as I get SOMEWHERE,” Alice added as an explanation.
“Oh, you’re sure to do that,” said the Cat, “if you only walk long enough.” (Carroll, 1865)

Systems thinking is an opportunity- an opportunity to implement effective and sustainable interventions by setting goals and understanding the complexities involved. It allows researchers and policy makers to study the effects that an implementation has within all building blocks of a system and to take into consideration, the role and influence of stakeholders at every stage of the policy making and implementation process. Systems thinking tools have been used in many disciplines (computer science, business, engineering, forestry, etc), and it is time for health researchers and policy makers to seize the opportunity as well.

6 WHO building blocks of a health system

A recently published supplement in Heath Policy and Planning,  Systems thinking for health systems strengthening in LMICs: seizing the opportunity, explores systems thinking in public health practice. This supplement comes as a follow-up to the 2009 report, Systems Thinking for Health Systems Strengthening. Here, Systems Thinking is defined as an approach to problem solving that examines the complex nature of systems and employs tools to study system dynamics and feedback mechanisms, placing an emphasis on the role and influence of all stakeholders.

Thus far in looking at systems strengthening interventions, the approach has been predominately based on ‘detail complexity.’ That is, simplifying the system into object versus dynamic relationships, creating a vacuum of static options for health system decision-making. Limited capacity, lack of funding, inadequate time frames, and lack of demand, from both researchers and research funders are among the barriers for the design and operationalization of more dynamic, systems-based evaluation schemes. Insufficient evaluations, however, bear an even heavier cost on the health system by creating redundancies and weaker structures.

This cost holds especially true in the implementation of innovations in the health system, especially in lower socioeconomic groups. Innovative health technologies, medicines, diagnostics, practices, and institutional arrangements have lower uptake and adoption in lower resource settings due to weaker health systems, low political will, and sometimes, cultural stigma.

Dr. Rifat Atun offers systems thinking as a means of better analyzing the “the context, health system elements, institutions, adoption systems, problem perception and the innovation characteristics within these” to better grasp the short and long term effects of an innovation, thus optimizing its chances at being adopted within the health system. With low uptake of innovations due to weak system infrastructure, especially in low resource settings where funds are also low, hope and opportunity lies with the “pooling of resources, talents and strategies from across a range of actors and organisations.”

The health sector is a complex adaptive system. Therefore, positive and negative effects of policy decisions, a variety of stakeholder interests, power and interaction between multiple actors, and prediction of delayed and distal impacts of policy decisions should all be considered for effective decision-making. Case studies included in this supplement explore tools, such as causal loop diagrams and stakeholder management, which can help to understand effects that may otherwise be overlooked. Without these considerations, negative feedback loops may occur throughout the different layers of the health system over time, leading to the deterioration of an intervention.

Systems thinking tools of interest:  
Social Network Analysis Methods Monte Carlo Simulation
Program Budgeting & Marginal Analysis Systems Dynamics Modeling
Concept Mapping Causal Loop Diagrams

These tools serve not only to explore relationships and to predict unintended effects, but to also ensure a follow-through plan that integrates interventions into the health system in a feasible, context-appropriate and sustainable manner.

Systems thinking simplifies the understanding of complex adaptive systems by calling for a systematic way of setting aside assumptions, involving local stakeholders and capturing effects that may otherwise have led to duplication of services, inefficiencies and policy resistance.  As more and more health researchers and policy makers incorporate systems thinking strategies into intervention design, implementation and evaluation, health system innovations will have an increased chance in connecting people with their right to health.


Adam, T. & Da Savigny, D. 2012. Systems thinking for health systems strengthening in LMICs: seizing the opportunity. Health Policy and Planning. 27:S4

Carroll, Lewis. 1865. Alice’s Adventures in Wonderland, New York:MacMillan.


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About the Author

Dena Javadi

is a Persian-born and Canadian-raised graduate from the University of British Columbia with a Bachelor of Science (Global Health). Dena has a deep abiding love of music, dancing whilst sitting, ultra-ordinary conversations and all things health systems. After working in the Alliance for Health Policy and Systems Research at the WHO for the past year, she will soon start her Masters of Public Health at Hopkins focusing on health systems.

One Response to Systems Thinking: Simplicity follows Complexity

  1. pooyan jadidfard says:

    Good Luck

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