Quality of care reform: a case for systems thinking and human centred design capabilities


  1. Elizabeth Mitgang, health specialist1,
  2. Kojo Twum Nimako, senior health specialist2,
  3. Jumana Qamruddin, global program lead, service delivery team1
  1. 1World Bank Group, Health Nutrition and Population, Washington, DC, USA
  2. 2World Bank Group, Health Nutrition and Population, Accra, Ghana
  1. Correspondence to: E Mitgang emitgangatworldbank.org

Elizabeth Mitgang and colleagues argue that building capacity in applied systems thinking and human centred design mindsets and methods can help improve quality of care, particularly in low and middle income settings

Health systems are social systems where outcomes for people and communities hinge on their ability to access high quality care when and where they need it. Yet globally, health systems often do not adequately take into consideration the interactions between people, communities, healthcare providers, and the enabling environment.1 The complementary approaches of applied systems thinking and human centred design are gaining traction as methods that can help tackle deficiencies and improve the quality of health services and experiences.1234

Systems thinking offers a practical way to see inter-relations and patterns of change rather than static “snapshots,” and to visualise emergent connections across the people and processes that comprise health systems.56 Human centred design augments this perspective. It focuses on engaging people affected by an identified challenge and designing solutions collaboratively for increased accessibility.3

Beyond improving the quality of medical products and services, systems thinking and human centred design can also offer substantial value in shaping large scale health system reforms for quality. These capabilities are critical for accelerating progress towards the sustainable development goals and are aligned with the Lancet Global Health Commission’s call for a shift from incremental quality interventions to a comprehensive reset of health systems.2

To help realise this shift, we should cultivate systems thinking and human centred design capabilities as both mindsets and skillsets among health professionals and policy makers who are central to conceptualising and implementing quality reforms. Conventionally, such decision makers are often clinicians or administrators, or from similarly technical disciplines.78 Although essential, technical backgrounds alone may not adequately equip them with the thinking and skills needed to deliver and sustain systems reform to respond to changing population needs.2 For example, as part of relocation planning at Johns Hopkins Hospital in the US, administrators developed design teams comprising institution staff and patients and trained themin systems thinking to establish a holistic understanding of how the hospital operated. This approach drew attention to overlooked aspects of the system such as patient transportation and environmental services and ultimately led to innovative designs that improved the quality of the hospital.9

To date, the application of systems thinking and human centred design for quality reform remains the exception, not the rule. This is arguably more so the case in low and middle income countries. This skills gap can be tackled by building capabilities among current and future health professionals and policy makers—who may themselves have clinical backgrounds. This can be done in the following ways.

First, medical education curriculums need reform. Advocates of medical education reform emphasise the importance of providing a more holistic approach to preventing and treating health conditions compared with traditional, disease focused curriculums.5 Integrating systems thinking and human centred design in foundational health education can help instil the mindsets and skillsets needed to design interventions and policies that consider the complexity and interconnectedness of people and health systems. After all, people function as part of a population and interact with an equally unpredictable environment.1011

Second, we must enhance the existing capabilities of health professionals as they execute quality of care reforms. One novel programme employs an applied framework that centralises systems thinking and human centred design as two core capabilities.4 A team-based learning experience for health system leaders, the programme makes these methods accessible and directly employable as these leaders design and implement reforms. Introducing this programme pedagogy among health professionals involved in system level quality reforms is a high-impact entry point for improving and sustaining quality of care at scale. For example, service delivery redesign is an innovative process for system level reform that focuses on reorganising care to improve quality and health outcomes by centring the needs and expectations of the people in the system.211 Training health professionals in systems thinking and human centred design as part and parcel of the service delivery redesign process can ensure that these concepts are integrated into their approach to designing, implementing, and sustaining effective, people centred, system level quality reform in real time.4

The goal for systemic quality improvement backed by strong national commitments is shared globally.2 Capability building programmes and reform processes are helping to advance toward this goal, while systemic updates to health professional education curriculums are well within reach. We can harness this momentum and realise high quality health systems that can accelerate improvement in quality of care and promote people centred care for all. We now call on the global health community to mainstream systems thinking and human centred design capabilities as essential mindsets and skillsets to tackle deficits in systemic quality of care and beyond.


  • Competing interests: None declared.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

  • This article is part of a collection proposed by the World Health Organization and the World Bank and commissioned by The BMJ. The BMJ peer reviewed, edited, and made the decision to publish these articles. Article handling fees are funded by the Bill & Melinda Gates Foundation. Jennifer Rasanathan, Juan Franco, and Emma Veitch edited this collection for The BMJ. Regina Kamoga was the patient editor.


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