Advancing the application of systems thinking in health: understanding the dynamics of neonatal mortality in Uganda
Agnes Semwanga Rwashana1, Sarah Nakubulwa, Margaret Nakakeeto-Kijjambu
1Information Systems Department, College of Computing and Information Sciences, Makerere University, P,O, Box 7062, Kampala, Uganda. asemwanga@cit.ac.ug.
Insights
Uganda faces high neonatal mortality due to complex health system factors. Systems thinking and causal loop diagrams reveal key intervention points for reducing newborn deaths.
Area of Science:
- Public Health
- Systems Science
- Neonatal Health
Background:
- Uganda has the 5th highest neonatal mortality rate globally, with 43,000 deaths annually.
- Despite existing programs, insufficient focus is placed on the critical first month of life.
- There's a need for innovative solutions addressing neonatal health complexities and health system interactions.
Purpose of the Study:
- To empirically understand the causes of stagnating neonatal mortality in Uganda.
- To apply a systems thinking approach to explore neonatal health dynamics and health system interplay.
- To identify high-leverage intervention points for reducing neonatal mortality.
Main Methods:
- Conducted literature reviews and interviews in Kampala with mothers, health workers, and policymakers.
- Utilized causal loop diagrams (CLDs) to map factors contributing to neonatal mortality.
- Validated CLDs with local and international stakeholders.
Main Results:
- Developed CLDs illustrating demand and supply-side factors influencing neonatal mortality, including maternal health and service availability.
- Identified reinforcing and balancing feedback loops within the complex system.
- Highlighted potential high-leverage points: girls' education, improved socioeconomic status, enhanced health facility supervision, and resource allocation.
Conclusions:
- Causal loop diagrams effectively synthesized theoretical concepts to understand feedback loops in Uganda's neonatal mortality.
- This systems-level understanding is crucial for developing targeted strategies to reduce neonatal deaths.
- The study provides a foundation for exploring potential interventions and their impact on neonatal mortality rates.
Background:
Of the three million newborns that die each year, Uganda ranks fifth highest in neonatal mortality rates, with 43,000 neonatal deaths each year. Despite child survival and safe motherhood programmes towards reducing child mortality, insufficient attention has been given to this critical first month of life. There is urgent need to innovatively employ alternative solutions that take into account the intricate complexities of neonatal health and the health systems. In this paper, we set out to empirically contribute to understanding the causes of the stagnating neonatal mortality by applying a systems thinking approach to explore the dynamics arising from the neonatal health complexity and non-linearity and its interplay with health systems factors, using Uganda as a case study.
Methods:
Literature reviews and interviews were conducted in two divisions of Kampala district with high neonatal mortality rates with mothers at antenatal clinics and at home, village health workers, community leaders, healthcare decision and policy makers, and frontline health workers from both public and private health facilities. Data analysis and brainstorming sessions were used to develop causal loop diagrams (CLDs) depicting the causes of neonatal mortality, which were validated by local and international stakeholders.
Results:
We developed two CLDs for demand and supply side issues, depicting the range of factors associated with neonatal mortality such as maternal health, level of awareness of maternal and newborn health, and availability and quality of health services, among others. Further, the reinforcing and balancing feedback loops that resulted from this complexity were also examined. The potential high leverage points include special gender considerations to ensure that girls receive essential education, thereby increasing maternal literacy rates, improved socioeconomic status enabling mothers to keep healthy and utilise health services, improved supervision, and internal audits at the health facilities as well as addressing the gaps in resources (human, logistics, and drugs).
Conclusions:
Synthesis of theoretical concepts through CLDs facilitated our understanding and interpretation of the interactions and feedback loops that contributed to the stagnant neonatal mortality rates in Uganda, which is the first step towards discussing and exploring the potential strategies and their likely impact.
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