1. Systems Dynamics Analysis of Health Systems
Resilience: Case Studies from Cote d’Ivoire and Nigeria
Alastair Ager,1
Martina Lembani,2
Helen de Pinho,1
Peter Delobelle,2
Christina Zarowsky 2,3
1
Columbia University, Mailman School of Public Health, New York 2
University of the Western Cape,
School of Public Health, Cape Town 3
Université de Montréal, Canada
Background
Boko Haram attacks have severely disrupted state infrastruc-
ture Photo credit: [aboutondostate.net]
Methods
Discussion
There is increasing interest in applying the concept of resil-
iencetounderstandwaysofpromotingrobusthealthservice
delivery in contexts of acute or chronic crisis. Identifying
key sources of vulnerability and health systems structures
and designs that promote resilient functioning can inform
policy-making across a broad range of settings.
We have applied a systems dynamics approach of group
model building (GMB) in a series of case studies in settings
where instability has provided major challenges to the op-
eration of the health system. We report on two case studies:
one focused on the continuation of HIV services during
the political crisis that followed the disputed Presidential
election in Cote d’Ivoire in 2010; the other on provision of
MNCH services interventions in northern Nigeria in the
context of the insurgency by Boko Haram.
Our approach to GMB has involved:
The systems models generated indicate potential points
of leverage for stakeholders to maximize health systems
resilience in contexts of adversity. While analyses reveal
unique features of each context, there are indications
of recurrent systems patterns that promote resilience.
Group model building using a systems dynamics approach
promises to be an effective methodology for convening
stakeholderstodevelopacommonviewofsourcesofhealth
systems vulnerability and potential points of leverage to
strengthen resilience. It represents a powerful technology
abletocapturekeyaspectsofthedynamicscrucialtohealth
systems functioning.
• Defining a focal problem
• Interviewing key stakeholders
• Convening a participatory group modeling
session where key factors are elicited and linkages
between them identified
• Refining the resulting systems model using
available data sources; and
• Disseminating the model to support current and
future health systems planning and preparedness.
A series of scripts have been developed to facilitate the pro-
cesses of participatory modeling. These include guides for
stakeholder interviews and preliminary thematic analysis;
development of ‘rich pictures’ for scenario elaboration;
identification of drivers and outcomes through inter-rela-
tionship diagraphing; ‘seed model’ specification and mod-
el development using Vensim modeling software.
This case study was completed in collaboration with the Part-
nership for Reviving Routine Immunization in Northern Ni-
geriaandMaternalNewbornChildHealth(PRRINN-MNCH)
programme. The focus of the analysis was the impact of the
ongoing Boko Haram insurgency on the health system in Yobe
State and the steps taken to respond to presented challenges.
Attacks from the militant group popularly known as Boko
Haram (‘against Western education’) began in Yobe in 2011,
initially targeting the police and churches. From 2012 the at-
tacks/bombings expanded to target mosques, schools, hospi-
tals, banks, burning villages and kidnapping community lead-
ers.
Many organizations terminated their operations in the state,
while others limited their operations. Health workers, espe-
cially those not indigenous to the state, fled to other states.
When indigenous health workers abandoned their work plac-
es during periods of major insecurity they generally returned
when the situation improved.
Some health facilities were directly attacked, with insurgents
taking away drugs, hospital equipment, ambulances and oth-
er vehicles. Health workers were abducted and killed in blasts
when traveling to or from work. Movement for health work-
ers and patients to health facilities was a major challenge due
to curfews imposed by the security services.
Thirty-nine key informant interviews, followed by dis-
cussions with eleven participants during group model
building (GMB), suggested the following:
• Insecurity challenged utilization of health services and
health care quality through two major pathways: access
to services and availability of human resources.
• The mobilization of political will from the State Gover-
nor and health managers activated crucial systems path-
ways that mitigated these impacts.
• Staff commitment and motivation and community re-
sources and cohesion were additional key sources of sys-
tems resilience.
• Availability of drugs and consumables at facilities was,
in general, not severely disrupted due to flexibility in
patterns of supply.
• Financial barriers to service access were partly averted
by the introduction of a state drug subsidy scheme in
2009.
•Levelofsecurityinfluencedtheuseofservicesinacom-
plex manner. If the number of attacks was high the utili-
zation of services was low because patients were afraid to
travel to the health facilities. Many patients that sought
care did so when critically ill and requiring urgent med-
ical attention.
• If an attack involved a large number of casualties health
facilities nearby would be filled with patients injured
during an attack. Areas that experienced fewer or no at-
tacks reported a general increase in patient attendance
because people had migrated to those places.
CASE STUDY: Health Service Provision in Yobe State,
Nigeria in the Context of the Boko Haram Insurgency
Conclusion
• Strong political will to urgently act on and mitigate the
effects of the crisis including increased coordination and
information sharing at different levels of the health system.
• Flexibility in drug supply systems through increasing
amount of drugs at facility level and decentralization of
drug supply chain systems.
• Flexibility in allocation of staff jobs and working condi-
tions such as task-shifting and change of working hours.
• Narrowing focus to strategic activities that are critical.
• Coordination and information sharing on security to en-
able transfer of drug supplies and consumables and for the
safety of health workers.
• Mechanisms of promoting health worker retention and
recruitment of indigenous workers who have inherent mo-
tivational interests to serve their own people and provision
of accommodation to within health facility premises to
promote human resource availability during crisis times.
These included:
• Flexibility in the disbursement of drugs to patients. Instead
of the normal one month doses, patients were provided with
2-3 months drug supplies at the beginning of the crisis and
later reduced to 10-20 days supplies as the crisis continued.
There was also flexibility across clinics to share drugs with
those running short of stocks, with ICAP staff monitoring
supplies and facilitating transfer
• High staff retention despite severe transport disruption and
the closure of banking system. Staff absences averaged be-
low 10% across 17 affected districts. Such staffing levels were
maintained despite non-payment of salaries.
• ARV continuation was explicitly prioritized over other HIV
services.
• External support for the procurement of drugs and in pro-
viding security information to the in-country team to ensure
the safety of health workers who needed to travel to clinics.
Civil unrest and violence following the disputed presi-
dential elections of November 2010 caused significant
disruption of HIV services. In some areas, forces occu-
pied hospitals, using them as their operating base, and
some hospital equipment such as CD4 count machines
and air conditioners was stolen or vandalized. Travel –
especially along the main north-south corridor – was
significantly disrupted making it difficult to transport
drugs from the central medical stores in Abidjan to the
rest of the country. Banks were closed for a period of
two months, which further exacerbated disruption.
The case study was conducted principally from the per-
spective of the staff of ICAP, an organization providing
technical assistance to the Ministry of Health to support
family-focused and multidisciplinary HIV services in
health facilities across the country.
Interviews with current and former ICAP staff and the
subsequent group model building discussion identified
a wide range of issues that were seen to have supported
the continuation of services – especially HIV treatment
- in the period following the disputed election.
Clinics in Cote d’Ivoire faced severe challenges
Complex systems model developed by stakeholders in Nigeria and refined to show key pathways of threat and response
Complex systems model developed by stakeholders in Cote d’Ivoire and refined by modeling team to reflect key themes
Stakeholders participate in a systems mapping exercise
CASE STUDY: Technical Assistance to HIV Services in
Cote d’Ivoire in the Context of Civil Unrest Following the
Disputed Presidential Election of 2010
For more information contact:
Dr Martina Lembani (Project Coordinator)
martina_lembani@yahoo.co.uk
Dr Alastair Ager (Principal Investigator)
aa2468@columbia.edu