Health Systems Science: A New Pillar in Health Professions Education and Practice

Introduction

World Health Organization defines health systems as “all the activities whose primary purpose is to promote, restore or maintain health” (De Savigny & Adam, 2009). Health systems are fundamentally socio-technical, driven primarily by human interactions rather than purely technical components. Unlike hardware or software systems, they involve complex emotional, physical, and social dimensions, making optimization through standard engineering approaches insufficient. Understanding health systems requires examining relationships and behaviors among clinicians, patients, caregivers, and community members. It also demands an analysis of how societal and environmental contexts influence these human dynamics. Health System Sciences (HSS) aim to systematically explore and improve these intricate interactions to enhance overall healthcare delivery and outcomes.

Conceptualizing Health Systems Science

HSS rapidly emerges as the third pillar of medical and health professions education, alongside basic and clinical sciences (Skochelak et al., 2020). This discipline emphasizes understanding how health systems function and how healthcare delivery can be systematically improved. HSS equips health professionals with critical skills in systems thinking, change management, policy, informatics, and population health. As global health challenges, such as pandemics and the burdens of chronic diseases, increasingly strain healthcare infrastructures, there is a growing recognition that clinical and biomedical knowledge alone is insufficient. Physicians, nurses, and policymakers must also understand the healthcare systems within which they work and how these systems influence patient and population health outcomes.

HSS integrates interdisciplinary fields such as public health, health economics, informatics, management, and policy-making, creating a holistic view of healthcare delivery. This systems-based approach is designed to address the complex nature of modern health challenges. While basic science encompasses fundamental biological knowledge, clinical science focuses on patient diagnosis and treatment, HSS addresses the broader context in which healthcare occurs. This includes how social determinants of health, such as housing, education, and socioeconomic status, affect patient outcomes, making it necessary for professionals to think beyond individual patient encounters and toward the improvement of entire healthcare systems (Skochelak et al., 2020).

Health System Strengthening through HSS

Health system strengthening involves creating resilient healthcare systems capable of effectively responding to crises and routine care needs. Through HSS, policymakers and healthcare professionals are trained to use evidence-based methods and technology to enhance healthcare delivery. For example, clinical informatics and digital health technologies enable healthcare systems to quickly respond to health threats through improved data management and service coordination.

One illustrative case is Rwanda’s transformation after the 1994 genocide. Rwanda implemented robust community-based health insurance systems, strengthened primary care infrastructure, and established clear governance structures. These measures significantly improved health outcomes and prepared Rwanda to respond efficiently to COVID-19, achieving rapid and extensive vaccination coverage significantly ahead of regional peers (Nkengasong & Tessema, 2020).

Conversely, the fragmented healthcare approach in the United States during COVID-19 highlighted the dangers of weak system integration. Despite having advanced medical infrastructure, inadequate coordination between public health and healthcare systems resulted in severe outcomes. This case emphasizes the importance of integrating HSS education into healthcare training to bridge these gaps effectively (Bilinski & Emanuel, 2020).

Complex Adaptive Systems in Healthcare

Health Systems Science draws heavily from the theory of complex adaptive systems (CAS). Healthcare systems are not linear or predictable; they consist of dynamic, interdependent components (patients, clinicians, hospitals, policies) that constantly adapt and evolve. This understanding shifts the perspective from rigid control to adaptive management that embraces uncertainty and continuous learning (Braithwaite et al., 2018).

The contrasting responses to COVID-19 in Italy’s Lombardy and Veneto regions highlight the relevance of complex adaptive systems in healthcare. Veneto’s community-based, decentralized strategy facilitated rapid adaptation and containment of the virus. In contrast, Lombardy’s centralized, hospital-centric model experienced overwhelmed hospitals, illustrating how rigid systems are vulnerable during crises. These contrasting experiences underline the importance of flexibility and decentralized decision-making in managing complex health emergencies (Pisano, Sadun, & Zanini, 2020).

Integration of care across Public Health and clinical medicine

HSS emphasizes addressing population-level health determinants and integrating care across public health and clinical medicine. This integration enables more effective responses to pandemics, chronic diseases, and health inequities. The Ebola crisis in West Africa demonstrated that rapid health system strengthening and multi-sectoral approaches are critical for effective disease control. Countries lacking pre-existing robust systems struggled significantly, emphasizing the importance of comprehensive HSS frameworks (Gostin & Friedman, 2015).

HSS-trained professionals are adept at recognizing how external factors impact health outcomes. For instance, addressing the social determinants of health can significantly reduce chronic disease burdens by aligning medical interventions with broader public health initiatives (Marmot et al., 2008).

Change Management in Healthcare

Integrating HSS into healthcare practice involves substantial change management, which requires adaptable, inclusive leadership and iterative learning processes. Healthcare systems, particularly hospitals and educational institutions, often face resistance to change due to entrenched traditional practices and hierarchies.

Effective change management involves clearly communicated vision, participatory leadership, and continual adjustments based on feedback. Engaging multidisciplinary teams, including clinicians, public health workers, and patients, ensures broader buy-in and sustainable improvements. This collaborative approach aligns closely with HSS principles, fostering a resilient healthcare culture (Skochelak et al., 2020).

An excellent example of successful change management is the Veterans Health Administration’s (VHA) effort to reduce hospital-acquired infections. Utilizing principles of HSS, VHA implemented nationwide quality improvement strategies based on robust data analytics, interprofessional collaboration, and continuous training, dramatically improving patient safety outcomes. This illustrates how systemic, data-driven change can significantly enhance healthcare quality and patient outcomes (Perlin et al., 2013).

Incorporating HSS into Health Professions Education

Educating health professionals in HSS prepares them to manage and lead healthcare improvement initiatives effectively. Medical schools worldwide are integrating HSS into their curricula to produce clinicians capable of systems-level thinking and leadership. Programs like the AMA’s Accelerating Change in Medical Education Consortium have demonstrated significant benefits, preparing graduates to navigate and improve healthcare systems proactively (Gonzalo et al., 2019).

  At Princess Nourah bint Abdulrahman University in Saudi Arabia, a systematic process was used to integrate HSS into the medical curriculum. This involved restructuring existing courses and adding new ones to cover core domains such as population health, health policy, and clinical informatics (Otman et al., 2023).

Incorporating HSS into Health Professions Education programs offers numerous benefits, including the development of a more comprehensive understanding of healthcare systems and the enhancement of skills necessary for effective healthcare delivery. However, this integration also presents several challenges, such as the need for curriculum restructuring and faculty development.

Benefits of Incorporating Health System Sciences

·       Enhanced Systems Thinking: HSS education fosters systems thinking, which is crucial for understanding the complexities of healthcare systems. This approach helps students appreciate the interactions between different components of healthcare delivery, leading to improved patient care and healthcare outcomes (Bian et al., 2024) (Lee et al., 2024).

·       Focus on Health Equity: Integrating HSS with a focus on health equity can address disparities in healthcare delivery. By centering curricula around equity, students learn to consider social determinants of health and advocate for underserved populations, ultimately improving patient outcomes (Roy et al., 2024).

·       Interprofessional Collaboration: HSS curricula often include interprofessional education, encouraging collaboration among healthcare professionals from various disciplines. This collaboration is essential for effective patient care and can be enhanced through systems engineering approaches (Ferreira et al., 2023) (Gonzalo et al., 2023).

·       Preparation for Evolving Healthcare Needs: As healthcare systems evolve, HSS education equips future healthcare professionals with the skills needed to adapt to changes in healthcare policy, economics, and technology. This preparation is vital for providing value-based care and improving healthcare delivery structures (Othman et al., 2023) (Bharel et al., 2024).

 Challenges of Incorporating Health System Sciences

·       Curriculum Restructuring: Integrating HSS into existing curricula requires significant restructuring. This process involves identifying and modifying courses to include HSS content, which can be resource-intensive and time-consuming(Othman et al., 2023) (Yang et al., 2023).

·       Faculty Development: Effective HSS education necessitates faculty who are well-versed in systems thinking and HSS principles. Developing such faculty requires investment in training and professional development programs(Yang et al., 2023) (Gonzalo et al., 2023).

·       Cultural and Institutional Resistance: Traditional medical education has focused primarily on basic and clinical sciences. Introducing HSS as a third pillar may face resistance from institutions and educators accustomed to conventional curricula(Yang et al., 2023) (Na, 2023).

·       Sustainability and Financial Support: Implementing and sustaining HSS programs require financial resources and institutional support. Ensuring ongoing funding and stakeholder buy-in is crucial for the long-term success of these programs(Gonzalo et al., 2023) (Djokoto, 2023).

 While the integration of Health System Sciences into Health Professions Education programs presents challenges, it also offers significant opportunities to improve healthcare delivery and patient outcomes. Addressing these challenges requires a concerted effort from educational institutions, faculty, and healthcare professionals to embrace change and prioritize the development of comprehensive, systems-based curricula. This shift in focus can ultimately lead to a more equitable and effective healthcare system.

Furthermore, embedding HSS into educational standards and accreditation bodies reinforces its importance, ensuring continuous competency development throughout health professionals' careers. Such structured integration promotes long-term improvements in healthcare outcomes by fostering a workforce equipped to address system-wide challenges and drive sustainable changes.

Conclusion

Health Systems Science represents a significant medical and health sciences education and practice evolution. By emphasizing a systemic view, adaptability, and interdisciplinary collaboration, HSS offers a critical approach to addressing contemporary healthcare challenges. Its integration into health professions education, policy formulation, and healthcare management ensures a more resilient, responsive, and equitable healthcare system. Policymakers and health educators are encouraged to prioritize HSS training and implementation, preparing healthcare professionals not just to provide better patient care but also to actively shape and continuously improve the healthcare system itself.

References

AMA Teaching health systems science UPDATED Nov 20, 2024  https://www.ama-assn.org/education/changemeded-initiative/teaching-health-systems-science

Bian, J., Liu, N., Overgaard, S. M., Padman, R., Steel, P., Tiase, V. L., Whitcomb, C., Zhang, J., & Zhang, Y. (2024). Transdisciplinary perspectives for health systems science. 1(1). https://doi.org/10.1038/s44401-024-00002-3

Bilinski, A., & Emanuel, E. J. (2020). COVID-19 and excess all-cause mortality in the US and 18 comparison countries. JAMA, 324(20), 2100-2102.

Binagwaho, A., Mathewos, K., & Davis, S. (2020). Health equity in Rwanda: The new Rwanda, twenty years later. International Journal of Health Policy and Management, 9(3), 105-107.

Braithwaite, J., Churruca, K., Ellis, L. A., & Long, J. (2018). Complexity Science in Healthcare: Aspirations, Approaches, Applications and Accomplishments. Springer.

De Savigny, D. & Adam, T. Systems thinking for health systems strengthening. (World Health Organization, 2009).

Ferreira, S., Phelps, E., Abolmaali, S., Reed, G., & Greilich, P. (2023). Opportunities to apply systems engineering to healthcare interprofessional education. Frontiers in Medicine. https://doi.org/10.3389/fmed.2023.1241041

Gonzalo, J. D., Chang, A., Wolpaw, D. R., & Skochelak, S. E. (2019). Health Systems Science curricula in undergraduate medical education: Identifying and defining a potential curricular framework. Academic Medicine, 94(2), 190-196.

Gonzalo, J. D., Hamilton, M. C., DeWaters, A., Munyon, R., Miller, C. E., Wolf, H., Wolpaw, D. R., & Thompson, B. M. (2023). Implementation and Evaluation of an Interprofessional Health Systems Science Professional Development Program. https://doi.org/10.1097/ACM.0000000000005144

Gostin, L. O., & Friedman, E. A. (2015). Ebola: A crisis in global health leadership. Lancet, 384(9951), 1323-1325.

Lee, H.-Y., Im, S. J., Shin, S., Kim, J.-A., & Song, J. (2024). Effect of Early Clinical Exposure based Health Systems Science course in the Korean Medical Education: A Prospective Observational Study. https://doi.org/10.21203/rs.3.rs-4941094/v1

Marmot, M., Friel, S., Bell, R., Houweling, T. A., & Taylor, S. (2008). Closing the gap in a generation: Health equity through action on the social determinants of health. Lancet, 372(9650), 1661-1669.

Nkengasong, J. N., & Tessema, S. K. (2020). Africa needs a new public health order to tackle infectious disease threats. Cell, 183(2), 296-300.

Othman, M., Al Shahrani, A. S., Almohanna, A. M., & Allabun, S. (2023). Integration of Health System Sciences: Process and Content at One Saudi Medical School. https://doi.org/10.21203/rs.3.rs-3272565/v1

Pisano, G. P., Sadun, R., & Zanini, M. (2020). Lessons from Italy’s response to coronavirus. Harvard Business Review. Retrieved from https://hbr.org/2020/03/lessons-from-italys-response-to-coronavirus

Plsek, P. E., & Greenhalgh, T. (2001). Complexity science: The challenge of complexity in health care. BMJ, 323(7313), 625-628.

Roy, M., Lee, R. S., & Furfari, K. (2024). Centering equity in a longitudinal health systems science curricula. Medical Teacher, 1–4. https://doi.org/10.1080/0142159x.2024.2313575

Skochelak, S. E., Hawkins, R. E., Lawson, L. E., Starr, S. R., Borkan, J., & Gonzalo, J. D. (Eds.). (2020). Health Systems Science (2nd ed.). Elsevier.