Systems Thinking

In our complex system, we use nonlinear thinking to understand how things work. We try to understand the relationships—human and operational—within a system. To improve our complex system, we need a new mindset to expand our understanding of work, patients, and co-workers. That new mindset is systems thinking.

A systems thinker sees how the parts of an organization interact and how effectively people are working together. This new way of thinking permits us to see things we didn’t see before. Expanded thinking allows us to recognize and imagine ways of solving problems by grasping entire processes and systems. Such thinking also reinforces the idea that the whole is greater than the sum of its parts.

Systems thinking is fundamental to quality improvement, which requires a unity of purpose. Having a unified or shared purpose allows individuals and departments to come together, so all energy is directed toward achieving a single goal. Systems thinking creates a drive for never-ending improvement. It instills a sense of doing good work and learning to do it better while we work.

Systems thinking utilizes habits, tools and concepts to develop an understanding of the interdependent structures of dynamic systems. When individuals have a better understanding of systems, they are better able to identify the leverage points that lead to desired outcomes.

  • Systems thinking is a management discipline that concerns an understanding of a system by examining the linkages and interactions between the components that comprise the entirety of that defined system.
  • The whole system is a systems thinking view of the complete organisation in relation to its environment. It provides a means of understanding, analysing and talking about the design and construction of the organisation as an integrated, complex composition of many interconnected systems (human and non-human) that need to work together for the whole to function successfully.
  • Whole systems are composed of systems, the basic unit, which comprise several entities (e.g. policies, processes, practices and people) and may be broken down into further sub-systems.
  • Systems may be thought about as having clear external boundaries (closed) or having links with their environment (open). An open systems perspective is the more common and realistic.
  • The boundaries of a whole system may be chosen and defined at a level suitable for the particular purpose under consideration; e.g. the education system or a complete school system.
  • Similarly, systems can be chosen and defined at different levels and can operate alongside each other as well as hierarchically; e.g. the finance system, the decision-making system, the accountability system.
  • An organisation as an entity can suffer systemic failure. This occurs in the whole system or high-level system where there is a failure between and within the system elements that need to work together for overall success.
  • Factors in systemic failure may include confused goals, weak system-wide understanding, flawed design, individual incentives that encourage loyalty to sub-ordinate (rather than super-ordinate) goals, inadequate feedback, poor cooperation, lack of accountability, etc.
  • Whole system success requires a performance management system that is pitched above the level of individual systems and their functional leadership. Features may include group or team-level goal-setting, development, incentives, communication, reviews, rewards, accountability. The aim is to focus on what binds individuals together and what binds systems together rather than functional silo performance.
  • Whole system failure may co-exist alongside functional success. The leadership of silos may individually be successful but not be sufficiently integrated into the whole system owing to a shortcoming of systems design, management or understanding.
  • A whole system can succeed only through managers collaborating in and across a number of functional systems. The whole system can fail only if leadership at the level of the whole system fails, and where several senior managers are involved. Hence, such failure may be labelled a systemic failure of leadership.
  • In cases of systemic failure, individual executives who operate at a lower sub-system level may be free of responsibility and blame. They may argue (correctly) that it was the wider system that failed. They may claim that particular systems that integrate with their own work let them down. However, responsibility and accountability for the successful design and running of the (integrated) ‘whole system’ should rest somewhere.
  • Understanding and anticipating how the whole system is intended to work, actually works, and how it may buckle under pressure, can practically elude and defeat most executives. To avoid censure for this tough challenge, they sometimes seek recourse to the often hollow mantra “lessons will be/have been learned”. They also try to divert attention and reassure investors by referring to a single bad apple (e.g. a ‘rogue trader’), behind which usually lurks a systemic failure.
  • The leadership challenge is accentuated by the realisation that for every legitimate, official or consciously designed system (which is intended to be and is supposedly rational) there is a shadow system. The shadow system is where all the non-rational issues reside; e.g. politics, trust, hopes, ambitions, greed, favours, power struggles, etc.
  • The system can confuse, overpower, block, and fail leadership. But leadership can fail the system. A major failure of leadership within, across or down an organisation is referred to as ‘systemic’.

(Extract from Chapter 12 ‘Leadership and Systems’ in The Search for Leadership: An Organisational Perspective, Triarchy Press)


In global health, we are concerned with both theory and practice, and are in need of models that match the complex conditions in which we work. A common thread of all these theories, methods, and tools is the idea that the behavior of systems is governed by common principles that can be discovered and expressed. They are all helpful in trying to conceptualize the systems in place. Some are more focused on ways to change the system to produce better outcomes. In using these theories, methods, and tools, we are reminded by the statistician George EP Box that “all models are wrong, but some are useful” [35]. It is to these uses that we now turn.

In much of public health and medicine, we use research evidence on the efficacy of interventions to inform decisions with an expectation about their future effect. Some systems thinking methods and tools, such as scenario planning, can also be used to explicitly forecast future events. However, even then, such methods are intended to be used for identifying possible outcomes to provide insights on how to prepare for them rather than fixing on any particular outcome.

In his landmark address on “Why Model?”, which provided inspiration for this essay, Joshua Epstein identified 16 reasons other than prediction on why to model [36]. Most of these reasons are applicable to systems thinking more broadly. Many of these specific reasons relate to being able to explain how things work, and systems thinking is particularly useful to explaining how complex systems work. Many of models can be used for testing the viability of policy interventions in a safe and inexpensive way – agent based models, systems dynamics models, and scenario planning are particularly useful for these purposes. In this journal supplement, for example, Bishai et al. present a very simple systems dynamics model to illustrate the trade-offs and unintended consequences of policy choices related to allocation to preventive and curative services [29].

Systems thinking approaches can also provide guidance on where to collect more data, or to raise new questions and hypotheses. The methods and tools help us to make explicit our assumptions, identify and test hypotheses, and calibrate our models against real data. One of the frustrations of health planners and researchers has been the aspiration that interventions shown to be effective at small scale or in a research setting cannot be simply replicated at large scale or to reach populations that are most vulnerable. Systems thinking methods and tools are increasingly being used to explain epidemics and to inform programmatic expansion efforts [5, 6].

One of the more compelling reasons to use systems thinking approaches is to inspire a scientific habit of mind. Beyond the contributions of any particular theory, method, or tool, the practice of systems thinking can reinforce what Epstein calls a “militant ignorance”, or commitment to the principle that “I don’t know” as a basis for expanding scientific knowledge. Systems thinking adds to the theories methods and tools we otherwise use in global health, and provides new opportunities to understand and continuously test and revise our understanding of the nature of things, including how to intervene to improve people’s health. And for those who value thinking and doing in global health, that can only be a good thing.


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