The development of sustained African health policy and systems research and teaching capacity requires the consolidation and strengthening of relevant research and educational programmes as well as the development of stronger engagement between the policy and research communities. The Consortium for Health Policy and Systems Analysis in Africa (CHEPSAA) will address both of these issues over the period 2011 - 2015. CHEPSAA’s goal is to extend sustainable African capacity to produce and use high quality health policy and systems research by harnessing synergies among a Consortium of African and European universities with relevant expertise. This goal will be reached through CHEPSAA’s five work packages:
assessing the capacity development needs of the African members and national policy networks;
supporting the development of African researchers and educators;
strengthening courses of relevance to health policy and systems research and analysis;
strengthening networking among the health policy and systems education, research and policy communities and strengthening the process of getting research into policy and practice;
project management and knowledge management.
The CHEPSAA project is led by Lucy Gilson (Professor: University of Cape Town & London School of Hygiene and Tropical Medicine).
PARTNERS
Health Policy & Systems Programme within the Health Economics Unit, University of Cape Town, South Africa
School of Public Health, University of the Western Cape, South Africa
Centre for Health Policy, University of the Witwatersrand, South Africa
Institute of Development Studies, University of Dar es Salaam, Tanzania
School of Public Health, University of Ghana, Legon, Ghana
Tropical Institute of Community Health, Great Lakes University of Kisumu, Kenya
College of Medicine, University of Nigeria Enugu, Nigeria
London School of Hygiene & Tropical Medicine, United Kingdom
Nuffield Centre for International Health and Development, University of Leeds, United Kingdom
Karolinska Institutet, Sweden
Swiss Tropical and Public Health Institute, University of Basel, Switzerland
CHEPSAA WEBSITE
www.hpsa-africa.org
Suggested citation
CHEPSAA. (2013). Introduction to Complex Health Systems: Course Outline for Public Discussion (October 2013). Cape Town, Consortium for Health Policy & Systems Analysis in Africa.
This document is an output from a project funded by the European Commission (EC) FP7-Africa (Grant no. 265482). The views expressed are not necessarily those of the EC.
CHEPSAA. (2013). Introduction to Complex Health Systems: Course Outline for Public Discussion (October 2013). Cape Town, Consortium for Health Policy & Systems Analysis in Africa.
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This is the first in a series of teaching materials currently being developed by CHEPSAA. These materials are intended as resources which can be developed and used to enhance postgraduate teaching and learning related to health policy and systems. The courses are set at a Master’s degree level, and intended for inclusion within a broader Master’s programme, but could also be offered as stand- alone short courses.
This document provides a short description and outline of this course, as well as noting some of the resources which will be available with it, to give a sense of what it will look like and what it will cover. This outline was developed during, and after, two week-long workshops held in Cape Town in May 2012 and 2013, in which experienced educators intensively discussed the curriculum and content. We would appreciate feedback on the outline as developed thus far, in order to incorporate as much relevant input as possible for the full course, which is to be available online later in 2013. The full course will include facilitators’ notes, resources and more detail.
Overall course aim
This course aims to provide an introduction to the components, actors and inter-relationships of the health system, as well as core principles of systems thinking and policy analysis, as a platform for health systems analysis, action and research.
Course description
It is proposed that this would be a course within a Master’s degree programme. It could also be offered as a stand-alone short course of approximately five days.
As a course within a Master’s programme, it should involve students in approximately 120 hours of study or 12 credits. This estimate is based on the concept of ‘notional hours’ of learning which is integral to the national qualifications frameworks which some countries have already implemented, and others are in the process of developing. Within such a framework, the course would offer 12 credits towards a qualification, which, at Master’s level, might carry between 120 and 200 credits in total.
A suggested time structure for the course is as follows:
Contact time
3 hour sessions x 10
30 hours
Non-contact time
Self-study (reading, research, discussion)
60 hours
Assessment time (assignments, group tasks and summative assessments e.g. examinations)
30 hours
Total Course time
120 hours
This time-frame could be adjusted to various delivery models, with more or less contact time, depending on the different needs of differing situations. Obviously, the more contact time is offered, the less self-study time will be necessary.
Target audience
The target audience for this course is:
mid-level managers in the public sector or in NGOs
future health policy and systems analysts and researchers
senior policy makers
academics from other fields of Public Health and beyond.
Although this is an introductory course, providing an entry into the field of health policy and systems, it is aimed at students who are well qualified and experienced in their own areas of expertise. They bring this expertise to the course, but must nonetheless learn to use new ideas and concepts. Some students are likely to come from medical backgrounds and may be unfamiliar with social science concepts, on which this course is largely based. Others may be challenged by limited practical experience of health systems. The course is designed to introduce new concepts but also to allow students to draw on their own experience, and to provide opportunities for shared, peer learning.
Approach to teaching and learning
The course seeks to develop higher order academic and conceptual skillsrelated to the field. Where new concepts are introduced, these will be scaffolded in such a way that students can engage with them iteratively during the course, to build understanding and skills.
A foundation of the course design is the identification and introduction of threshold concepts. These are the key ideas, set out below, underpinning the course content and philosophical perspective, with which students should be familiar and conversant.
Threshold Concepts
People make sense of the system around them and act based on their understandings and mind sets.
Health systems are socially constructed; they exist within contexts and histories.
Health systems are integrative by nature, and consist of complex inter-relationships; we all have a role in the system.
Health systems consist of ‘hardware’ and ‘software’.
Health system effectiveness is a ‘whole system’ judgement rather than one based on the effectiveness of specific interventions.
Power is everywhere: in agency, service delivery and decision-making.
Everyone has a part to play in the system, working towards shared goals.
The health system is knowable and changeable.
The health system is a complex adaptive system.
In addition, the mode of learning promoted in the course is based on constructive alignment of graduate attributes and learning outcomes with learning activities and assessment, so that the course is consistent and coherent, and its aims transparent. The approach to learning is also intended to be actively participatory and collaborative; to promote critical, autonomous thinking and learning; to develop analytical and communication skills; and to encourage a reflective, open-minded approach to health policy and systems. To this end, the course draws on principles of authentic learning, with tasks rooted in real world experience and deep learning, in which students are encouraged to think holistically and see connections and complex relationships. In this way the course provides opportunities for students to draw on and use their own experience in applying new concepts to real world examples and settings.
Assessment
The approach to assessment aims as far as possible to include relevant and realistic tasks that help students to apply the theory and concepts learned on the course, using a range of thinking and study skills. The tasks are designed to include a variety of assessment methods and tools which enable students to show their learning on the course. This course will be assessed through formative assessments (designed to provide students with feedback on progress and inform further development in the remainder of the course) and summative assessments (a measure of achievement made in respect of students’ performance in relation to the intended learning outcomes of the course).
The formative assessment will consist of a portfolio of written tasks which students will complete individually or in groups and which should be handed in during the duration of the course. These tasks will comprise of a range of tasks which will practice academic engagement, writing for specific audiences, application of frameworks and translating lessons learned in class to students’ own contexts.
The summative assessment will be a written assignment (long essay) deriving from sessions 8 and 9 and drawing on all aspects of the course, which will be submitted at the end of the course.
In addition, if assessment rules in particular institutions require, students may also need to sit an examination, as another summative assessment. Details of assessment criteria and weightings will be suggested when the course is developed more fully.
Course learning outcomes
This course has six learning outcomes. While not all sessions address all of the outcomes, most of them weave through majority of the sessions, albeit with different weightings in each session. The introductions to each session outlined below signal the focus of sessions and their specific aims.
By the end of this course students are expected to be able to:
Show understanding of the dynamic and complex nature of health systems by reflecting on and describing their value bases and functioning, as well as the central roles and behaviours of a range of actors;
Discuss health systems as social constructions, influenced by broader political and economic forces, generating public value and contributing to societal development;
Apply these understandings to assessment of their own health system and comparison between health systems;
Apply relevant analytical skills and an understanding of complex systems in order to develop ideas about action to strengthen health systems;
Develop the personal communication, teamwork and leadership skills which are important for supporting health system change;
Demonstrate understanding of and openness to different perspectives on the nature of health systems.
Course Outline
The course begins by considering what a health system is and why it is important, and introducing some frameworks for thinking about health systems. One specific instance of health system development, the Thai experience, is considered in some detail as an example of ‘whole system’ improvement - and linked to current international debates around Primary Health Care and Universal Health Coverage. It then goes on to outline the central role of people in health systems, their values and mind sets, and why these are important for understanding of and intervention in health systems.
Throughout the course a number of case studies are used to illustrate and apply concepts and ideas, and students are encouraged to apply the new ideas to their own contexts as well. Complex adaptive systems thinking is, finally, introduced as an approach for understanding and changing health systems.
Each of the sessions outlined below is designed with 2-3 hours contact time, incorporating lectures and other input (e.g. video and podcast), group and individual tasks and discussion. After each session students are expected to spend approximately 3-6 hours on reading, preparation and other personal study.
Note: The full set of materials, which will become available on the CHEPSAA website later in 2013, will provide guidance and resources for activities in each session.
Session 1: Introductions; What is a Health System?
This session aims to orientate students into the course, and provides an introduction to thinking about health systems, how they are constructed and function in particular contexts, their value bases and their place in history and society.
Topics and activities :
Introductions and course overview: Participatory activity
What is a health system and why is it important?: Group work
The Political economy of African health systems: Lecture; Podcast on a Nigerian example; ‘Gap-minder’ review and task
Self- study:
Reading on introduction to health systems
Gather information on timelines of own countries’ health system development
Session 2: Frameworks for describing and analysing health systems and policy
This session fleshes out the discussion of what a health system is and why it is important in a society. Concepts, measures and frameworks for thinking about systems are introduced and the integrative nature of health systems is emphasised. Students then apply these to their own country’s health system. The session also introduces reflection on teamwork skills.
Topics and activities :
Students’ discuss own countries’ health systems histories and make comparisons between them: Group discussion and feedback;
Understanding systems: Flashmob Game
Ideas and frameworks for thinking about health systems and policy: Video and lecture; group discussion.
Application of frameworks to specific country scenarios: Thinking pairs to prepare for homework
Readings and discussion: what makes for effective group work?
Self-study – Application of frameworks to own country health system
Draw diagram of your own health system and reflect on its values base
Portfolio task 1: Apply health systems frameworks to analyse own countries’ health system
Read Thai case study with guiding questions
Session 3: Understanding the Thai experience of health system development
This session deepens the ideas about what health systems are: that they are complex and integrative, and that health system development is a long-term task, influenced by broader political, economic and social forces, and requiring persistence, vision and adaptability. It introduces the notion of system effectiveness, and relevant indicators. It uses a case study of Thailand to develop ideas about understanding and strengthening health systems, including the interactions between system hardware and software. It encourages personal reflection on teamwork skills.
Topics and activities :
Review reading of Thai case study: Individual reading
Thai case study as an example of health systems strengthening: Discussion in group, class discussion
Lecture: wrap-up of the Thai experience
Self-study
Reflection on group work and own contribution
Personal thinking: What are you learning from the Thai case study about opportunities for HS strengthening in your country?
Read in preparation for session 4
Session 4: Whole system change – Primary health Care (PHC) and Universal Health Coverage (UHC)
This session develops further and consolidates ideas about what systems are and how to strengthen them. It focuses on primary health care and universal health coverage as changes affecting all aspects of the health system. It then asks students to apply lessons from the Thai case study as well as UHC and PHC to think about and articulate concise ideas about strengthening key elements of their own country’s health system by writing a policy briefing note as an exercise in communication.
Topics and activities:
PHC and UHC as ‘whole systems’ change’: lecture and discussion.
Lessons from Thai experience and UHC/PHC debate for own country health systems: individual work, thinking pairs, plenary discussion
What is required for developing a policy briefing?: Lecture, Input/handout
Develop a policy brief on an aspect of Thai experience for own health system: preparatory brainstorming exercise
Self-study:
Portfolio task 2: Develop a policy briefing note on strengthening an aspect of own health system environment, learning from Thai experience.
Guided reading of one of a range of papers on people in systems – with a focus on actors and decision-making
Session 5: Recognising agents in health systems
This session focuses on the central role of people and their roles in health systems. It focuses on the importance of people’s values and mind sets, agency and power, as drivers of their behaviour and that all these impact on how health systems function.
Topics and activities:
Readings about people in systems: Group discussion of range of papers; plenary discussion
Systems dynamics - getting to people in the system: Squaring the circle exercise
What drives health system actors?: Lecture and plenary discussion
Overview of stakeholder analysis: Brief input
Self-study:
Read stakeholder analysis scenario
Readings to support reflection on the concepts introduced in the session, particularly power, and its influence over health system change.
The focus of this session is on applying the ideas from session 5 and thinking about the roles of health system actors in relation to the process of system change. It looks at actors’ values, beliefs, mind sets, and power relations, and considers how behaviour and attitudes influence system performance. It then considers the significance of the different views actors have of health systems and the world, for health systems development, reflecting also on the interaction between system software and hardware.
Topics and activities:
Stakeholder analysis in practice: Group exercise using actor maps based on budgeting scenario; de-briefing
Different paradigms of knowledge: Read and re-discuss papers on people in systems, hardware-software etc.
Re-thinking about actors in own contexts, their location, power and mind sets: Thinking pairs.
Self-study
Portfolio task 3: Write up responses to papers discussed in session, focusing on people in systems, their different values, paradigms of knowledge; Thoughts on implications for managing change.
Reading for session 7
Session 7: Managing change in health systems
The main aim of this session is to introduce ideas for understanding and managing actors in health system change. Using a range of analytic frameworks it will focus on complexity and agency, but also, the understanding that health systems are knowable and changeable. Students will begin to develop strategies which support intervention and change in systems.
Topics and activities:
Managing agents and change: Discussion of readings; lecture (commitment planning; small wins, sense-making)
Managing agents and commitment planning: Group task developing strategies for managing change using SHA scenario; feedback discussion
Self-study
Portfolio task 4: take forward thinking about strengthening own developed in policy briefing note incorporating ideas from this session: developing strategies for change in own environment.
Guided reading of allocated case studies in preparation for next session.
Session 8: Intervening in health systems – case studies 1
This session starts to pull together all the strands of the course, by taking an in-depth look at a range of case studies of health systems’ change. Sessions 8 and 9 will talk to the integrative and dynamic nature of health systems, the centrality of actors in shaping these systems, and opportunities for generating change through addressing both the hard and the soft aspects of systems. The sessions will require teamwork skills.
Health system strengthening – what the case studies reveal: Guided group discussion and activities based on specific case study.
Input and discussion of skills for making presentations: Buzz groups; group discussion
Self-study
Prepare group presentation for next session.
Session 9: Intervening in health systems– case studies 2
This session continues the in-depth look at case studies and what they reveal about health policy and systems in practice, calling for the ability to demonstrate an understanding of health systems’ contribution to public value and societal development. The session will also require presentation and team work skills, and allow reflection on both. The group presentations will be marked by students in class (as a peer assessment), and the marks will become part of the portfolio and the formative assessment marks.
Topics and activities:
Presentation of case studies: Group presentations and feedback
Cross case review of experiences; implications for action in and across cases: Plenary discussion
Reflection on teamwork and leadership in relation to the group task: Plenary discussion
Self-study
Portfolio task 5: Write guided reflection on learning from the case study group work, task and presentation.
Reading on CAS in preparation for session 10
Session 10: Health system complexity and change
The final session aims to wrap up the course by deepening the understanding of complex adaptive systems and linking this understanding to the different concepts, frameworks and ideas introduced in the course. The session will place particular emphasis on the analytic skills of students in being able to apply new concepts in different contexts, and on communicating ideas and understandings to an audience.
Topics and activities:
Discussion of papers applying complex adaptive systems (CAS) thinking and concepts to health systems: Student-led journal club
Application of CAS concepts to case studies discussed in sessions 8 and 9: Group discussion.
Linking CAS thinking to core concepts discussed in the course: Wrap-up lecture and discussion
Course evaluation: Group discussion; individual written task
Self-study:
Assignment: Write a long essay based on the case studies and presentations of sessions 8 and 9. Detailed instructions to follow. This assignment will form the summative assessment and will be submitted one week after session 10.
Alignment of assessment to learning outcomes
Assessment item
Learning Outcome to be assessed
FORMATIVE ASSESSMENT
Portfolio task 1: (Session 2)
Apply health systems frameworks to analyse own countries’ health system
LO 1: Show understanding of the dynamic and complex nature of health systems by reflecting on and describing their value bases and functioning, as well as the central roles and behaviours of a range of actors.
LO 2: Discuss health systems as social constructions, influenced by broader political and economic forces, generating public value and contributing to societal development;
LO 3: Apply these understandings to assessment of your own health system and comparison between health systems
Portfolio task 2: (Session 4)
Develop a policy briefing for strengthening an aspect of own health system.
LO 4: Apply relevant analytic skills and an understanding of complex systems in order to develop action to strengthen health systems;
LO 5: Apply communication, leadership and teamwork skills in order to develop action to strengthen health systems
Portfolio task 3: (Session 5)
Write up responses to papers discussed in session, focusing on people in systems, their different values, paradigms of knowledge; Thoughts on implications for managing change.
LO 4: Apply relevant analytic skills and an understanding of complex systems in order to develop action to strengthen health systems;
LO 6: Demonstrate understanding of and openness to different perspectives on the nature of health systems, by expressing these in writing or orally.
Portfolio Task 4: (Session 7)
Take forward thinking about strengthening own developed in policy briefing note incorporating ideas from this session: developing strategies for change in own environment.
LO 3: Apply understandings of the complex and socially constructed nature of health systems to assessment of your own health system and comparison between health systems
LO 4: Apply relevant analytic skills and an understanding of complex systems in order to develop action to strengthen health systems
Portfolio task 5: (Session 9)
Write guided reflection on learning from the case study group work, task and presentation.
LO 1: Show understanding of the dynamic and complex nature of health systems by reflecting on and describing their value bases and functioning, as well as the central roles and behaviours of a range of actors.
LO 5: Apply communication, leadership and teamwork skills in order to develop action to strengthen health systems
LO 6: Demonstrate understanding of and openness to different perspectives on the nature of health systems, by expressing these in writing or orally.
Group presentations in session 9 will be marked by peers and marks included in formative assessment mark.
LO 1: Show understanding of the dynamic and complex nature of health systems by reflecting on and describing their value bases and functioning, as well as the central roles and behaviours of a range of actors.
LO 5: Apply communication, leadership and teamwork skills in order to develop action to strengthen health systems
LO 6: Demonstrate understanding of and openness to different perspectives on the nature of health systems, by expressing these in writing or orally.
SUMMATIVE ASSESSMENT
Assignment: Write a long essay based on the case studies and presentations of sessions 8 and 9. Detailed instructions to follow. This assignment will be submitted one week after session 10.
