Complexity and evidence in health sector decision-making: lessons from tuberculosis infection prevention in South Africa

Abstract To better understand and plan health systems featuring multiple levels and complex causal elements, there have been increasing attempts to incorporate tools arising from complexity science to inform decisions. The utilization of new planning approaches can have important implications for the types of evidence that inform health policymaking and the mechanisms through which they do so. This paper presents an empirical analysis of the application of one such tool—system dynamics modelling (SDM)—within a tuberculosis control programme in South Africa in order to explore how SDM was utilized, and to reflect on the implications for evidence-informed health policymaking. We observed group model building workshops that served to develop the SDM process and undertook 19 qualitative interviews with policymakers and practitioners who partook in these workshops. We analysed the relationship between the SDM process and the use of evidence for policymaking through four conceptual perspectives: (1) a rationalist knowledge-translation view that considers how previously-generated research can be taken up into policy; (2) a programmatic approach that considers existing goals and tasks of decision-makers, and how evidence might address them; (3) a social constructivist lens exploring how the process of using an evidentiary planning tool like SDM can shape the understanding of problems and their solutions; and (4) a normative perspective that recognizes that stakeholders may have different priorities, and thus considers which groups are included and represented in the process. Each perspective can provide useful insights into the SDM process and the political nature of evidence use. In particular, SDM can provide technical information to solve problems, potentially leave out other concerns and influence how problems are conceptualized by formalizing the boundaries of the policy problem and delineating particular solution sets. Undertaking the process further involves choices on stakeholder inclusion affecting whose interests may be served as evidence to inform decisions.

[1]  J. Parkhurst,et al.  System dynamics modelling and the use of evidence to inform policymaking , 2022, Policy Studies.

[2]  A. Grant,et al.  Health system influences on the implementation of tuberculosis infection prevention and control at health facilities in low-income and middle-income countries: a scoping review , 2021, BMJ Global Health.

[3]  Jill A. Kuhlberg,et al.  Promoting knowledge to policy translation for urban health using community-based system dynamics in Brazil , 2021, Health Research Policy and Systems.

[4]  E. Martin TRANSLATING EVIDENCE INTO POLICY IMPACT: A CALL TO ACTION FOR FORMATIVE POLICY EVALUATION TO PROMOTE EVIDENCE‐BASED DECISIONMAKING , 2021 .

[5]  G. Gartlehner,et al.  [WHO Guidelines on Tuberculosis Infection Prevention and Control]. , 2020, Gesundheitswesen (Bundesverband der Arzte des Offentlichen Gesundheitsdienstes (Germany)).

[6]  J. Webster,et al.  Understanding evidence use from a programmatic perspective: conceptual development and empirical insights from national malaria control programmes , 2020, Evidence & Policy: A Journal of Research, Debate and Practice.

[7]  J. Seeley,et al.  Tuberculosis infection prevention and control: why we need a whole systems approach , 2020, Infectious Diseases of Poverty.

[8]  Negar Darabi,et al.  System dynamics modeling in health and medicine: a systematic literature review , 2020 .

[9]  R. Ehrlich,et al.  The high-quality health system ‘revolution’: Re-imagining tuberculosis infection prevention and control , 2019, Journal of clinical tuberculosis and other mycobacterial diseases.

[10]  George P. Richardson,et al.  Systems Thinking, Mapping, and Group Model Building , 2019, Handbook of Group Decision and Negotiation.

[11]  Sondoss Elsawah,et al.  System Dynamics Modeling to Inform Defense Strategic Decision-Making , 2019, System Dynamics.

[12]  Luis F. Luna-Reyes,et al.  Modeling and Simulation as Boundary Objects to Facilitate Interdisciplinary Research , 2018, Systems Research and Behavioral Science.

[13]  D. Andersen,et al.  Using a Stakeholder Analysis to Improve Systems Modelling of Health Issues: The Impact of Progesterone Therapy on Infant Mortality in Ohio , 2018, Systems Research and Behavioral Science.

[14]  Sibel Eker,et al.  Participatory system dynamics modelling for housing, energy and wellbeing interactions , 2018 .

[15]  A. V. van Rensburg,et al.  Voices from the frontline: barriers and strategies to improve tuberculosis infection control in primary health care facilities in South Africa , 2018, BMC Health Services Research.

[16]  Rifat Atun,et al.  Dynamic modeling approaches to characterize the functioning of health systems: A systematic review of the literature. , 2017, Social science & medicine.

[17]  Alison Kitson,et al.  Using Complexity and Network Concepts to Inform Healthcare Knowledge Translation , 2017, International journal of health policy and management.

[18]  J. Parkhurst The politics of evidence: from evidence-based policy to the good governance of evidence , 2016 .

[19]  Paul Cairney,et al.  The Politics of Evidence-Based Policy Making , 2016 .

[20]  Gemma Carey,et al.  Systems science and systems thinking for public health: a systematic review of the field , 2015, BMJ Open.

[21]  Laura J. Black,et al.  Meaning-making in the process of participatory system dynamics research , 2015 .

[22]  Andrew Page,et al.  Applications of system dynamics modelling to support health policy. , 2015, Public health research & practice.

[23]  K. Lancaster Social construction and the evidence-based drug policy endeavour. , 2014, The International journal on drug policy.

[24]  Kathryn Oliver,et al.  New directions in evidence-based policy research: a critical analysis of the literature , 2014, Health Research Policy and Systems.

[25]  T. Lorenc,et al.  A systematic review of barriers to and facilitators of the use of evidence by policymakers , 2014, BMC Health Services Research.

[26]  Peter S. Hovmand,et al.  Introduction to Community-Based System Dynamics , 2014 .

[27]  Laura J. Black,et al.  When visuals are boundary objects in system dynamics work , 2013 .

[28]  Sandra L. Resodihardjo The Governance of Problems: Puzzling, Powering, and Participation , 2012 .

[29]  Jean-Louis Denis,et al.  Knowledge exchange processes in organizations and policy arenas: a narrative systematic review of the literature. , 2010, The Milbank quarterly.

[30]  A. Cresswell,et al.  From "Need to Know" to "Need to Share": Tangled Problems, Information Boundaries, and the Building of Public Sector Knowledge Networks , 2009 .

[31]  P. Escalante Tuberculosis , 1904, Annals of Internal Medicine.

[32]  Erik-Hans Klijn,et al.  Complexity Theory and Public Management , 2008 .

[33]  Trisha Greenhalgh,et al.  Recognizing rhetoric in health care policy analysis , 2008, Journal of health services research & policy.

[34]  H. Davies,et al.  Using Evidence: How research can inform public services , 2007 .

[35]  Pierre Lascoumes,et al.  Introduction: Understanding Public Policy through Its Instruments—From the Nature of Instruments to the Sociology of Public Policy Instrumentation , 2007 .

[36]  Gary Goertz Introduction to the Special Issue “Causal Complexity and Qualitative Methods” , 2006, Political Analysis.

[37]  J. Homer,et al.  System dynamics modeling for public health: background and opportunities. , 2006, American journal of public health.

[38]  Paul R. Carlile,et al.  A Pragmatic View of Knowledge and Boundaries: Boundary Objects in New Product Development , 2002, Organ. Sci..

[39]  K. Stave Using system dynamics to improve public participation in environmental decisions , 2002 .

[40]  Jac A. M. Vennix,et al.  Group model building effectiveness: a review of assessment studies † , 2002 .

[41]  George P. Richardson,et al.  Group model building: adding more science to the craft , 1997 .

[42]  Steven A. Cavaleri,et al.  Towards evaluation of systems‐thinking interventions: a case study , 1997 .

[43]  Jac A. M. Vennix,et al.  Building consensus in strategic decision making: System dynamics as a group support system , 1995 .