THE UNIVERSITY OF HULL HEALTH SYSTEMS THINKING: THE NEED FOR A MORE CRITICAL APPROACH being a Thesis submitted for the Degree of Doctor of Philosophy in the University of Hull by Luis Gomes Sambo MD, Universidade Agostinho Neto, Angola and Universidade Nova de Lisboa, Portugal Specialist in Public Health, Angolan Medical Post-Graduation College and Portuguese Medical Association Date: April 27, 2009 Abstract The present study intends to bring more insights and added value to Health Systems Thinking using systems ideas. It inquires about the current state of Health Systems Thinking, analyses different strengths of alternative systems approaches, and suggests what systems thinking can offer in order to improve the current understanding and the technical performance of Health Systems. It does not intend to develop a blue print model but rather a more critical approach to deal with some of the intractable problems encountered in current health sector reforms. The thesis is not expected to serve public health practitioners only but also systems thinking theorists, particularly those interested in social systems and pluralism in management sciences. Specifically, this thesis aims at analysing the current state of Health Systems Thinking; explores what other systems approaches can offer to enlighten health systems; and yields knowledge on Critical Health Systems Thinking. To achieve these aims the researcher articulated the study on the basis of the definition of health by the World Health Organisation, the interconnectedness among key health determinants and the global health challenges with particular emphasis in Sub-Saharan Africa. Critical Systems Thinking is the theoretical framework in which knowledge about systems is expressed and the current state of Health Systems Thinking is the area of concern in relation to which the researcher has aspirations. The methodology consists in two major steps conducting thought experiments in the context of three scenarios from the researcher‟s own experience. The first step uses Jackson‟s four major systems approaches and associated methodologies and yields learning about the current state of Health Systems Thinking; and the second step, using Critical Systems Practice in mode 2, generates a more critical approach to Health Systems Thinking. 2 Table of Contents Abstract ...................................................................................................................................... 2 Table of Contents ....................................................................................................................... 3 List of Figures ............................................................................................................................ 9 List of Tables ........................................................................................................................... 12 List of Abbreviations ............................................................................................................... 13 Acknowledgements .................................................................................................................. 17 CHAPTER 1 ............................................................................................................................ 18 1. INTRODUCTION ................................................................................................... 18 1.1. Background ............................................................................................................. 18 1.2. Aims of the research ............................................................................................... 19 1.3. Global health challenges ......................................................................................... 21 1.4. The Context in Sub-Saharan Africa - an example ............................................... 23 1.4.1. Reference to Determinants of Health in Sub-Saharan Africa ............................ 25 1.4.1.1. Political context ......................................................................................... 25 1.4.1.2. Socio-economic conditions ......................................................................... 27 1.4.1.3. Demographic conditions ............................................................................. 29 1.4.1.4. Environmental conditions ........................................................................... 30 1.4.1.5. Health Services/Systems ............................................................................. 31 1.4.2. Health status of people in Sub-Saharan Africa .................................................. 32 1.4.2.1. Malaria ....................................................................................................... 34 1.4.2.2 HIV/AIDS ................................................................................................. 35 1.4.2.3. Tuberculosis ................................................................................................ 36 1.4.2.4. Non-communicable diseases ...................................................................... 36 1.4.2.5. Maternal Health .......................................................................................... 37 1.4.2.6. Child Health ................................................................................................ 38 1.5. Current thinking about Health Challenges and Reforms ................................... 39 1.6 Chapter Summaries ................................................................................................. 43 1.7. Summary .................................................................................................................. 49 CHAPTER 2 ............................................................................................................................ 51 2. RESEARCH METHODOLOGY ...................................................................................... 51 2.1. Introduction ............................................................................................................. 51 2.2. Research Questions ................................................................................................. 52 2.3. The Argument for Qualitative Research Method ................................................ 53 2.4. Explorative Research goals .................................................................................... 56 2.5. Making the case for Thought Experiments ........................................................ 58 2.6. Multi-methodology in two Steps ....................................................................... 63 2.6.1. Thought Experiments using Jackson’s Key Methodologies to interrogate the current state of Health Systems thinking - Step 1 .................... 65 F1 ..................................................................................................................................... 66 2.6. 2 Thought Experiments using Creative Systems Practice mode2 to yield a more critical approach in Health Systems thinking (STEP 2) .................................... 72 2.7. Summary .................................................................................................................. 75 CHAPTER 3 ............................................................................................................................ 76 3. REVIEW OF SYSTEMS LITERATURE ........................................................................... 76 3.1 Introduction ........................................................................................................................ 76 3.2. Systems Ideas ........................................................................................................... 77 3 3.3. Systems Methodologies ........................................................................................... 84 3.3.1. Functionalist Systems Thinking ..................................................................... 84 3.3.1.1. Organizations-as-Systems ........................................................................... 85 3.3.1.2. Hard Systems Thinking ............................................................................... 89 3.3.1.4. Organizational Cybernetics ......................................................................... 92 3.3.1.5. Living Systems Theory ............................................................................... 95 3.3.1.6. Complexity Theory ..................................................................................... 96 3.3.1.7. Critique of the functionalist systems approach ........................................... 97 3.3.2. Soft Systems Thinking or Interpretive Systems Approach ................................ 97 3.3.2.1. Churchman‟s social systems design ............................................................ 98 3.3.2.2. Mason and Mitroff‟s strategic assumption surfacing and testing (SAST) . 98 3.3.2.3. Ackoff‟s social systems sciences ................................................................ 99 3.3.2.4. Checkland‟s soft systems methodology (SSM) ....................................... 100 3.3.3. Emancipatory Systems Approach ................................................................ 109 3.3.3.1. Emancipation as Liberation ...................................................................... 109 3.3.3.2. Emancipation through discursive rationality ............................................ 110 3.3.3.3. Emancipation through the oblique use of systems