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Systems thinking in healthcare

In this step, we look at systems thinking in healthcare.
My name is Amanda Royston, I’m an associate professor in healthcare leadership and management, based at Coventry University. I lead a team of 15 academics specialising in this field. I came to this having done a 35 year career within management roles, leading up to a stint of 15 years within the NHS in the UK. And come at it from very much a practical as well as an academic perspective. So when I think about systems thinking, I think it’s important to reflect on what we mean by that.
So in the year 2020 we were all expecting to be celebrating the Tokyo Olympics, in July, and when we think about the Olympics, it’s an example where multiple countries, over 200, come together to build and develop a sporting competition using the host of different agents, actors, organisations from across the globe. Sponsors sporting professional bodies, construction, clothing, tourism, and all these have to work together, to synchronise, to be able to, for that two weeks in July, to deliver the Olympics that we know about it. So if we think about that as a model and then you reflect on the COVID-19 crisis of 2020.
There are some strong similarities there, this is a worldwide event, where multiple agents from across the globe are working together, not only to learn about a new disease, but to supply hospitals and the frontline staff with the equipment they need, to look at how we can develop treatments and vaccines, how we can use existing manufacturers to start producing new things like ventilators and personal protective equipment, and universities on how we can support our healthcare services.
Again, everyone has to come together in order to actually achieve an end goal, and it really illustrates how healthcare is not a single thing, it is a multiple of different things, involving many different sectors, scientific, pharmaceuticals, research, engineering, supply chain, funding, NGOs, charities education, politicians, and they all have to work together to produce the end product and so really to be a leader within a healthcare setting you have to have a really thorough understanding of the systems in which you’re working in, and how to navigate through them successfully. So when I think about the healthcare leadership, I think what comes to me are, what I would say are three C’s.
First one being complexity, as you’ll have read about and as I’ve described, healthcare operates in a hugely complex environment, involving multiple sectors and as a health care leader and manager you need to understand how to navigate this complexity successfully, in order to achieve what trying to achieve. That leads on to the next C, which is very much around collaboration. You are, as a leader, not to make all the decisions, you don’t have control on all the variables that affect the outcome you’re trying to deliver. You’re relying on multiple different partners to do that and you have to find an effective way to collaborate across these sectors in order to achieve a common goal.
And when you look at complexity and collaboration as a leader you need courage, you need to be able to work in areas where you’re not the smartest person in the room, you’ll be working with professors and learned medics. You’ll be working with organisations that are funded in multiple different ways, are guided by lots of political issues, and you have to have the courage and the confidence to be able to stand up and speak and respond and to work together.
So the role of the leader in healthcare has never been more important than it is now, without good leadership, then fantastic clinicians, doctors, nurses, allied health professionals, scientists, and all our carers and cleaners, and everyone that we associate with healthcare, they can’t do their job unless there is good solid leadership up front and working towards a common goal.

In this video, we introduce you to Amanda Royston – an Associate Professor in Healthcare, Leadership and Management at Coventry University.

Amanda talks about the need for leaders to adopt a systems thinking approach to navigate the challenges and increasing complexity of health systems across the world.

In 2008 the World Health Organization (WHO) observed the following about health systems:

The responses of many health systems so far have been generally considered inadequate and naive… a system’s failure requires a system’s solution – not a temporary remedy.
(Savigny and Adam 2009: 39)
As we discussed in the previous step, systems thinking is an approach to problem-solving that views ‘problems’ as part of a wider, dynamic system. Through an increased understanding of a system’s fundamental characteristics, systems thinking allows us to see, with greater precision, how systems work.
The characteristics described in the rest of this step – especially when taken together – influence how systems, including health systems, respond to external factors or to intervention. The application of systems thinking in the health sector is accelerating a more realistic understanding of what works, for whom, and under what circumstances.
In 2009, the WHO stated that strengthening health systems was a core principle for itself, its member states and the global health community. Systems thinking was identified as a key enabler within this:
Systems thinking works to decode the complexity of a health system, then applies this understanding to design and evaluate interventions that maximize health and health equity.
(Savigny and Adam 2009: 30)
The WHO report highlights that in the constantly changing world of healthcare, where elements of the system are always acting, reacting and interacting in an often counter-intuitive process, it is crucial to understand how system-level interventions and policy directives might affect the reality of healthcare experienced at ground-level.
The WHO works to advance the principles of equity, universal coverage, and people-centred approaches – and within the complexity of this are advocating that policy-makers and funders must focus on system-strengthening initiatives that really work.
The WHO Health Systems Framework identifies six building blocks that must be in the place to deliver the overall goals of any health system.
Adapted from Savigny and Adam (2009: 31) – click on image to expand size.
In summary, the WHO emphasises three important points relating to systems thinking in healthcare:
  • Using a systems perspective to understand how health system building blocks, contexts and actors act, react and interact with each other is an essential approach in designing and evaluating interventions
  • Mainstreaming a stronger systems perspective in the health sector will assist this understanding and accelerate health system strengthening
  • Systems thinking offers a comprehensive way of anticipating synergies and mitigating negative emergent behaviours, with direct relevance for creating policies that are more system-ready

Your task

Consider the following quote:
‘… health services can be characterised as modern society’s most complex knowledge system’ (Saltman, Calltorp and de Roo 2011: 150).
Do you agree with this statement? Discuss your position in the comments area.

Further reading

Savigny, D., and Adam, T. (2009) Systems Thinking for Health Systems Strengthening [online] Alliance for Health Policy and Systems Research, World Health Organization. available from [21 April 2020]


Saltman, R., Calltorp, J., and de Roo, A. (2011) ‘Health Sector Innovation and Partnership’. in OECD Health Reform: Meeting the Challenge of Ageing and Multiple Morbidities. OECD Publishing, 143-168

Savigny, D., and Adam, T. (2009) Systems Thinking for Health Systems Strengthening [online] Alliance for Health Policy and Systems Research, World Health Organization. available from [21 April 2020]

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Understanding Systems Thinking in Healthcare

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