Advancing the application of systems thinking in health: analysing the contextual and social network factors influencing the use of sustainability indicators in a health system--a comparative study in Nepal and Somaliland.

BACKGROUND: Health systems strengthening is becoming a key component of development agendas for low-income countries worldwide. Systems thinking emphasizes the role of diverse stakeholders in designing solutions to system problems, including sustainability. The objective of this paper is to compare the definition and use of sustainability indicators developed through the Sustainability Analysis Process in two rehabilitation sectors, one in Nepal and one in Somaliland, and analyse the contextual factors (including the characteristics of system stakeholder networks) influencing the use of sustainability data. METHODS: Using the Sustainability Analysis Process, participants collectively clarified the boundaries of their respective systems, defined sustainability, and identified sustainability indicators. Baseline indicator data was gathered, where possible, and then researched again 2 years later. As part of the exercise, system stakeholder networks were mapped at baseline and at the 2-year follow-up. We compared stakeholder networks and interrelationships with baseline and 2-year progress toward self-defined sustainability goals. Using in-depth interviews and observations, additional contextual factors affecting the use of sustainability data were identified. RESULTS: Differences in the selection of sustainability indicators selected by local stakeholders from Nepal and Somaliland reflected differences in the governance and structure of the present rehabilitation system. At 2 years, differences in the structure of social networks were more marked. In Nepal, the system stakeholder network had become more dense and decentralized. Financial support by an international organization facilitated advancement toward self-identified sustainability goals. In Somaliland, the small, centralised stakeholder network suffered a critical rupture between the system's two main information brokers due to competing priorities and withdrawal of international support to one of these. Progress toward self-defined sustainability was nil. CONCLUSIONS: The structure of the rehabilitation system stakeholder network characteristics in Nepal and Somaliland evolved over time and helped understand the changing nature of relationships between actors and their capacity to work as a system rather than a sum of actors. Creating consensus on a common vision of sustainability requires additional system-level interventions such as identification of and support to stakeholders who promote systems thinking above individual interests.

Physical rehabilitation in post-conflict settings: analysis of public policy and stakeholder networks.

Physical rehabilitation plays a determinant role in post-conflict contexts to restore disabled citizens' mobility and independence. While the main objectives of any physical rehabilitation programme are to ensure that the services provided are accessible and of good quality to meet existing needs, it is intended that the services need to be supported over the long term by public health and social welfare authorities. This article presents the results of a study conducted in three post-conflict countries on the relationships between the level of commitment of national governments to rehabilitation services and the influence of social networks on national policy related to physical rehabilitation. From a policy and resource standpoint, the environment in Nepal is the most favourable for creating leverage at the national level to influence the commitment of ministries in the rehabilitation sector, compared with Cambodia and Somaliland. Stakeholder network analysis in Nepal, furthermore, reveals a dominant civil society and private sector supporting rehabilitation services, including intense involvement of local organisations and user groups. Implications for Rehabilitation Physical rehabilitation is not on the top of the agenda of governments in fragile states. The commitment and involvement of national authorities in the rehabilitation sector is positively influenced by civil society and international organisations. The denser the social network of the rehabilitation sector is, the more influence the actors can exert influence over national authorities.

Selection of sustainability indicators for health services in challenging environments: balancing scientific approach with political engagement.

Sustainability evaluation has become a key component of international health. However, evaluators have faced a number of challenges linked to the lack of consensus on the meaning of the concept of "sustainability". This paper aims to describe a methodology, the Sustainability Analysis Process, based on several conceptual frameworks and tested in five different countries in the physical rehabilitation sector. The methodology consists of five successive steps: (i) overview of the context; (ii) system boundary; (iii) consensus vision of sustainability, and derivation of stakeholder perspectives; (iv) selection of sustainability indicators and characterization and analysis of local system sustainability; and (v) verification and modification. The paper also discusses the place of the evaluator and researcher in the process: the methodology aims to help evaluators objectively measure the level of sustainability of a health system with the challenge of dealing with a subjective notion, the concept of sustainability, and a diversity of actors. The Sustainability Analysis Process also aims to capture the dynamics of systems by repeating the process on a regular basis. The methodology highlights the need for evaluators build consensus amongst stakeholders on a common vision of the future of a health system.

A qualitative and quantitative study of the surgical and rehabilitation response to the earthquake in Haiti, January 2010.

BACKGROUND: The disaster response environment in Haiti following the 2010 earthquake represented a complex healthcare challenge. This study was designed to identify challenges during the Haiti disaster response. METHODS: Qualitative and quantitative study of injured patients carried out six months after the January 2010 earthquake in Haiti to review the surgical inputs of foreign medical teams. RESULTS: Study findings revealed a need during the response for improved medical records and data gathering for regulation, quality assurance, coordination and resource allocation; wider adherence to standard patient referral mechanisms and protocols linking surgical service provision with appropriate hospital and community based rehabilitation services; a greater recognition of the impact of non-amputation injury, and the need for patients to have a greater say in their management and to be the keepers of their medical records. Key first steps to improving the international response are a minimum dataset and uniform reporting. CONCLUSION: This study showed that challenges for emergency medical response during the Haiti Earthquake involved issues of accountability, professional ethics, standards-of-care, unmet needs, patient agency and expected outcomes for patients in such settings: