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System thinking: an introduction

In this step, we introduce you to systems thinking.
The world in which we live and work is complex and rapidly changing, and so were the factors that determine our health. Consider obesity for example, there are many contributing factors including heredity, individual food consumption, personal activity levels, social influence, food production, etc. These factors are diverse, myriad, context dependent, and constantly changing. However when we fail to consider that complexity and health, we generally address one patient, program, disease, or policy, at a time without adequate consideration of that dynamic relationships, diverse perspectives, and invisible boundaries, which influence health. Such an approach often leads to unintended consequences.
Fortunately, complex problems don’t always require complex solutions, but we do need to shift the way we think about health and health improvement, we need to adopt a systems perspective, to find solutions to these important challenging problems. Systems approaches to change have emerged from a wide range of disciplines including systems thinking, complexity science, system dynamics, and complex adaptive systems. Such terms can be daunting to health professionals, who are new to these ideas. However we found that starting with three fundamental concepts, as suggested by Bob Williams, can be helpful. Interrelationships, perspectives, and boundaries. We will define these three concepts and then show you examples of how they apply to health improvement.
First we must consider interrelationships and the patterns of interactions between individuals and organisations over time. Sometimes global health organisations implement programs without considering the activities of other organisations working in the same area. This can lead to duplication of services in some areas and lack of services in others. It’s also important to consider the perspectives of those involved with and affected by health interventions. For example in Mozambique, mosquito nets intended for malaria prevention were delivered through a Health Organisation, however the nets were instead used for catching fish, because their intended use was misunderstood and there was a local need for food. In this example the local perspective was not adequately considered.
Often, without realising it, we form boundaries in our planning and activities that determine what perspectives we incorporate in value. For example a University public health department that dismisses input from outside of the department, will likely miss opportunities for positive and innovative change. Applying these three concepts in our individual clinics, organisations, and communities can transform the way that we approach health improvement. Once we start considering interrelationships, perspectives, and boundaries more earnestly, we will become aware of opportunities for improvement that we may not have previously considered. Here are a few examples of situations in our health work where applying a systems perspective might be beneficial.
A physician who receives very little feedback on her work over the course of years may be unaware of the perspectives of the patients. The lack of coordination between various global health initiatives can lead to unnecessary redundancies and inefficiency is created by boundaries between the organisations. Health care providers are often paid according to the number of patients that they care for instead of the quality of care that they provide. Financial reimbursement reform could be a significant leverage point in health care reform. Complex systems can be applied to a wide range of health activities. Your experience and context is likely very different from ours. What surprising patterns of interaction might you notice, by applying a systems perspective in your sphere of influence?
Can you identify boundaries that limit productive collaboration, such as social norms, that limit communication between organisations and cultures? What additional perspectives need to be considered to reach your community’s health vision? What new questions are you asking by taking a systems perspective? We as a global society need to change the way we approach every aspect of healthcare, to incorporate more systems thinking. We need a systems thinking revolution in health practice, policy research, and education. Thanks to support from the Doris Duke Charitable Foundation, African Health Initiative, and the Norwegian agency for development cooperation. We have formed an organisation called Systems Thinking for Capacity and Health, to advocate for these changes and we hope you’ll join us, thank you.

Leading and managing services within large complex systems like healthcare is challenging. The problems facing organisations are so complex that they defy simple solutions, and leaders are often trying to navigate many competing and conflicting challenges and relationships when making decisions.

Systems thinking is an approach to problem-solving that views ‘problems’ as part of a wider, dynamic system. It is the process of understanding how things influence one another as part of a whole. The video in this step provides a visual introduction to systems thinking and complexity in health.

The management science of systems thinking has evolved, as advocated by American academic Peter Senge in his seminal work The Fifth Discipline: The Art and Practice of the Learning Organisation.

Senge (2006) argues that organisations have become increasingly more complex and dynamic and, in order to deliver success, they must become a learning organisation. He identifies five key disciplines to becoming a learning organisation, of which systems thinking is the essential fifth element.

Senge argues that systems thinking integrates the four other elements of organisational learning, namely:

  • Personal mastery
  • Mental models
  • Building a shared vision
  • Team learning

Systems thinking involves much more than a reaction to present outcomes or events. It demands a deeper understanding of the linkages, relationships, interactions, and behaviours among the elements that characterise the entire system.

Commonly used in other sectors where interventions and systems are complex, systems thinking in the health sector shifts the focus to:

  • The nature of relationships among the building blocks
  • The spaces between the blocks (and understanding what happens there)
  • The synergies emerging from interactions among the blocks

We’ll explore this in more detail in the next step.


Senge, P. (2006) The Fifth Discipline: The Art and Practice of the Learning Organisation. London: Random House Business Books

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Understanding Systems Thinking in Healthcare

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