Cameron D. Willis

System tools for system change

BACKGROUNDnHealth system transformations are influenced by dynamic relationships within and between individuals and institutions, as well as political, educational and legislative factors. This article aims to promote awareness of five tools that recognise this complexity and that are proposed to have value for decision makers: concept mapping, social network analysis, system dynamics modelling, programme budgeting and marginal analysis, and the tools for knowledge management and translation.nnnMETHODSnThe authors briefly describe the methodological approach of each tool, provide a commentary on the conditions in which these tools have been employed, and discuss their impact on the processes and outcomes of system transformation. An international advisory panel was convened based on a combination of experience, expertise and perspective. The panel assisted in synthesising the evidence relating to each tool and, in partnership with the authors, refined the interpretation of the role and value of each tool for system transformation.nnnFINDINGSnThe tools discussed may impact the structural and procedural outcomes of transformation as well as the values, behaviours and attitudes of people undergoing change. The techniques described provide those undertaking transformation with methods to negotiate clinical, academic, political, organisational and cultural perspectives, and recognise the pivotal role of context in transformation.nnnCONCLUSIONSnThis review offers a novel synthesis of how these tools may add value to decision making for health policy. The tools discussed, while not a panacea to the challenges of large system change, provide methods that acknowledge the complexity of the transformative challenge and present innovative paths to co-produced solutions.

Advancing the application of systems thinking in health: advice seeking behavior among primary health care physicians in Pakistan

BackgroundUsing measles and tuberculosis as case examples, with a systems thinking approach, this study examines the human advice-seeking behavior of primary health care (PHC) physicians in a rural district of Pakistan. This study analyzes the degree to which the existing PHC system supports their access to human advice, and explores in what ways this system might be strengthened to better meet provider needs.MethodsThe study was conducted in a rural district of Pakistan and, with a cross-sectional study design, it employed a range of research methods, namely extensive document review for mapping existing information systems, social network analysis of physicians’ advice-seeking practice, and key stakeholder interviews for an in-depth understanding of the experience of physicians. Illustrations were prepared for information flow mechanism, sociographs were generated for analyzing social networks, and content analysis of qualitative findings was carried out for in-depth interpretation of underlying meanings.ResultsThe findings of this study reveal that non-availability of competent supervisory staff, a focus on improving performance indicators rather than clinical guidance, and a lack of a functional referral system have collectively created an environment in which PHC physicians have developed their own strategies to overcome these constraints. They are well aware of the human expertise available within and outside the district. However, their advice-seeking behavior was dependent upon existence of informal social interaction with the senior specialists. Despite the limitations of the system, the physicians proactively used their professional linkages to seek advice and also to refer patients to the referral center based on their experience and the facilities that they trusted.ConclusionsThe absence of functional referral systems, limited effective linkages between PHC and higher levels of care, and a focus on programmatic targets rather than clinical care have each contributed to the isolation of physicians and reactive information seeking behavior. The study findings underscore the need for a functional information system comprising context sensitive knowledge management and translation opportunities for physicians working in PHC centers. Such an information system needs to link people and resources in ways that transcend geography and discipline, and that builds on existing expertise, interpersonal relationships, and trust.

Networks to Strengthen Health Systems for Chronic Disease Prevention

Interorganizational networks that harness the priorities, capacities, and skills of various agencies and individuals have emerged as useful approaches for strengthening preventive services in public health systems. We use examples from the Canadian Heart Health Initiative and Albertas Primary Care Networks to illustrate characteristics of networks, describe the limitations of existing frameworks for assessing the performance of prevention-oriented networks, and propose a research agenda for guiding future efforts to improve the performance of these initiatives. Prevention-specific assessment strategies that capture relevant aspects of network performance need to be identified, and feedback mechanisms are needed that make better use of these data to drive change in network activities.

Scaling up complex interventions: insights from a realist synthesis

Preventing chronic diseases, such as cancer, cardiovascular disease and diabetes, requires complex interventions, involving multi-component and multi-level efforts that are tailored to the contexts in which they are delivered. Despite an increasing number of complex interventions in public health, many fail to be ‘scaled up’. This study aimed to increase understanding of how and under what conditions complex public health interventions may be scaled up to benefit more people and populations.A realist synthesis was conducted and discussed at an in-person workshop involving practitioners responsible for scaling up activities. Realist approaches view causality through the linkages between changes in contexts (C) that activate mechanisms (M), leading to specific outcomes (O) (CMO configurations). To focus this review, three cases of complex interventions that had been successfully scaled up were included: Vibrant Communities, Youth Build USA and Pathways to Education. A search strategy of published and grey literature related to each case was developed, involving searches of relevant databases and nominations from experts. Data extracted from included documents were classified according to CMO configurations within strategic themes. Findings were compared and contrasted with guidance from diffusion theory, and interpreted with knowledge users to identify practical implications and potential directions for future research.Four core mechanisms were identified, namely awareness, commitment, confidence and trust. These mechanisms were activated within two broad scaling up strategies, those of renewing and regenerating, and documenting success. Within each strategy, specific actions to change contexts included building partnerships, conducting evaluations, engaging political support and adapting funding models. These modified contexts triggered the identified mechanisms, leading to a range of scaling up outcomes, such as commitment of new communities, changes in relevant legislation, or agreements with new funding partners.This synthesis applies and advances theory, realist methods and the practice of scaling up complex interventions. Practitioners may benefit from a number of coordinated efforts, including conducting or commissioning evaluations at strategic moments, mobilising local and political support through relevant partnerships, and promoting ongoing knowledge exchange in peer learning networks. Action research studies guided by these findings, and studies on knowledge translation for realist syntheses are promising future directions.

Improving the performance of interorganizational networks for preventing chronic disease: identifying and acting on research needs.

This article describes the role of interorganizational networks in chronic disease prevention and an action research agenda for promoting understanding and improvement. Through a model of engaged scholarship, leaders with expertise and experience in chronic disease prevention networks helped shape research directions focused on network value, governance, and evolution. The guiding principles for facilitating this research include applying existing knowledge, developing network-appropriate methods and measures, creating structural change, promoting an impact orientation, and fostering cultural change.

Exploring the unanticipated effects of multi-sectoral partnerships in chronic disease prevention

Multi-sectoral partnerships are important parts of many public health efforts to address chronic diseases, such as cancer, diabetes, and cardiovascular disease. Despite the potential value of multi-sectoral approaches, uncertainty exists regarding their effects on individuals, organizations, communities and populations. This article reports on a study that examined the unanticipated effects (both positive and negative) of the Public Health Agency of Canadas (the Agency) Multi-sectoral Partnerships initiative, which supports more than 30 multi-sectoral partnership projects across Canada. Thirteen semi-structured interviews were conducted with staff from organizations participating in 3 diverse partnership projects as part of the Agencys multi-sectoral partnerships initiative. Multiple unanticipated effects were identified and organized into 4 themes: (1) insights about the flexibility and responsiveness of government; (2) access to new and valuable resources (people, skills, expertise); (3) opportunity to build new capacities; and (4) understanding realistic timelines for partnership activities and outcomes. While these effects were unanticipated for study participants, they resonate with insights from the literature on multi-sectoral partnerships. These results raise a number of questions for consideration as partnership initiatives continue to evolve, including the types of training that partners might need; the individual and organizational capacities required for partnership approaches; and the evaluation techniques that might be most useful to capture the non-linear effects of partnership approaches.

Outcomes of Interorganizational Networks in Canada for Chronic Disease Prevention: Insights From a Concept Mapping Study, 2015.

Introduction We conducted a mixed methods study from June 2014 to March 2015 to assess the perspectives of stakeholders in networks that adopt a population approach for chronic disease prevention (CDP). The purpose of the study was to identify important and feasible outcome measures for monitoring network performance. Methods Participants from CDP networks in Canada completed an online concept mapping exercise, which was followed by interviews with network stakeholders to further understand the findings. Results Nine concepts were considered important outcomes of CDP networks: enhanced learning, improved use of resources, enhanced or increased relationships, improved collaborative action, network cohesion, improved system outcomes, improved population health outcomes, improved practice and policy planning, and improved intersectoral engagement. Three themes emerged from participant interviews related to measurement of the identified concepts: the methodological difficulties in measuring network outcomes, the dynamic nature of network evolution and function and implications for outcome assessment, and the challenge of measuring multisectoral engagement in CDP networks. Conclusion Results from this study provide initial insights into concepts that can be used to describe the outcomes of networks for CDP and may offer foundations for strengthening network outcome-monitoring strategies and methodologies.