Applied systems thinking: a viable approach to identify leverage points for accelerating progress towards ending neglected tropical diseases

Abstract

Background: Systems thinking is a conceptual approach that can assist stakeholders in understanding complexity and making progress on persistent public health challenges. Neglected tropical diseases (NTDs), a complex global health problem, are responsible for a large disease burden among impoverished populations around the world. This aim of this study was to better discern the many complexities of the global NTD system in order to identify and act on leverage points to catalyse progress towards ending NTDs.Methods: Existing frameworks for systems change were adapted to form the conceptual framework for the study. Using a semi-structured interview guide, key informant interviews were conducted with NTD stakeholders at the global level and at the country level in Nigeria. The interview data were coded and analysed to create causal loop diagrams that resulted in a qualitative model of the global NTD system. Results:The complete qualitative model is discussed and presented visually as six separate sub-components that highlight key forces and feedback loops within the global NTD system. Conclusions:We identified five leverage points for NTD system change, namely (1) clarify the potential for and assess realistic progress towards NTD elimination, (2) increase support for interventions besides drug delivery, (3) reduce dependency on international donors, (4) create a less insular culture within the global NTD community, and (5) systemically address the issue of health worker incentives. The specific findings for NTDs raise a number of uncomfortable questions that have not been addressed, at least in part, because it is easier to continue focusing on 'quick win' solutions. The study provides a model of a systems thinking approach that can be applied to other complex global health and development challenges in order to understand complexity and identify leverage points for system change.

Rethinking the Top-Down Approach to Schistosomiasis Control and Elimination in Sub-Saharan Africa

“…This is hinged on the premise that the control and elimination of schistosomiasis, like all other NTDs, is affected by a multitude of social, cultural, economic, geographical and ecologic factors ( 28 ) which are interdependent, and for which the current use of praziquantel alone cannot solve. These interdependencies are best understood and addressed by looking at the system as a whole with a particular lens on weak points within the system ( 21 , 26 , 29 ).…”

“…Therefore, affected regions and communities should be seen as collaborators in dealing with schistosomiasis control and elimination. For most control programmes, the government attempts MDA as a broad strategy without looking in-depth at the peculiarities of these communities and their challenges which can be drivers of schistosomiasis infection and burden ( 26 , 28 , 29 ). Thus, the current one-size-fits-all intervention using a top-down approach may be a contributor to the limited success of schistosomiasis control and elimination in sub-Saharan Africa.…”

“…Fourth, given the neglected nature of the disease in most healthcare systems in sub-Saharan Africa, there is currently inadequate funding for the disease from the national governments which is likely to persist or worsen in the future once the current external funding and support reduce. There is also a potential for donor fatigue as current gains in treatment can be reversed when donation stops, because countries do not have sustainable strategies to own and incorporate programmes within their current healthcare systems ( 26 ). Lastly, the disease context is complex with an interplay of social, economic, political, and cultural factors ( 20 , 27 ) that may affect achieving the goals of the NTD 2021-2030 Roadmap ( 28 ).…”

Neglected tropical diseases as a barometer for progress in health systems in times of COVID-19

“…23 It provides a conceptual approach and methods to envisage alternative futures, identify tipping points for change, and open new ways of analysing, organising and communicating. 24 Rather than simply reacting to events, as has been the primary approach to this pandemic, systems thinking emphasises anticipating patterns of system behaviour based on a deeper understanding of underlying system structures and drivers. As there is no single solution for the multiple problems humanity faces, concerted efforts are needed to take into account the interplay across systems.…”

How to cope with uncertainty? Start by looking for patterns and emergent knowledge

“…This has been successfully applied to all scales of problems. Examples include: understanding the genetic components of aging 31 or the variability of clinical behaviours in glioblastoma multiforme 32 at the microlevel, the understanding of health 33,34 and the trajectory of patients' health and healing journeys, 35‐37 the management of an epidemic like SARS‐CoV‐2, 38 improving the health of indigenous people, 39 or ending neglected tropical diseases at the health policy level 40 …”