System approaches in governmental public health: Findings from an analysis of the literature
Keywords:governance, public health, service delivery, systems approach, systems thinking
The U.S. public health enterprise is a complex system of public and private partners, loosely coupled, which work together to improve the public's health. Contemporary governmental public health arises from patchworks of policies developed and revised over time in nearly all geopolitical jurisdictions in the country. Jurisdictions may then differ in what services are delivered, who governs those services, how services are delivered, and by whom. These decentralized and varied designs for public health systems present a challenge to the efficient and effective operation of the national public health enterprise. This challenge is an excellent candidate for study by systems science, given the discipline’s concepts and tools that may be used to investigate system structures and the implications of different structural configurations. Authors endeavored to first identify prior research that leveraged such methods. Authors designed a scoping review following a “rapid review” format that included most aspects of PRISMA systematic review methods. The scoping review utilized peer-reviewed and grey literature to identify how systems approaches have been used—or may be used—in the design or enhancement of public health governance structures and service delivery mechanisms. Researchers screened titles and abstracts against the research question and retained materials deemed relevant. The full text of retained materials were then reviewed against the study’s eligibility criteria: (1) discussion of at least one systems approach, (2) application in the public policy domain, and (3) application to governance or delivery of services; item #2 was expanded to “public policy” to include applicable cases where the search term “public health” was not included.. Data were then extracted and themed according to how approaches were applied to public health governance functions (e.g., policy development, resource stewardship) and service delivery mechanisms (e.g., independent delivery, cross-jurisdictional delivery). The final analytic sample included 34 articles from an initial pool of 1,128 unique citations that collectively described 25 systems approaches. Those approaches, such as ‘complex systems thinking’ and ‘system dynamics modeling,’ were described in as few as one and as many as seven materials. How those approaches were applied to governance functions and service delivery mechanisms differed greatly, with more examples for policy development, continuous improvement, and resource stewardship governance functions and independent and jointly delivered delivery mechanisms. Approaches were found to be utilized in relatively few situations with respect to governance functions or service delivery mechanisms but used for specific functional purposes (e.g., problem definition, decisionmaking, and systems design). These findings may indicate that few public health systems have used systems approaches to guide design or enhancement of public health systems when needs arise. The scarcity of literature on this topic presents a challenge, and further analytical studies are needed to inform evidence-based systems design strategies and applications.