Health Policy and Planning: Using causal loop diagrams for health system research (1) Systems thinking to achieve universal access to reliable healthcare information

22 November, 2022

Dear HIFA colleagues,

Please find below the citation, abstract and a comment from me.

CITATION: How to do (or not to do) using causal loop diagrams for health system research in low and middle-income settings

Rachel Cassidy et al.

Health Policy and Planning, Volume 37, Issue 10, December 2022, Pages 1328–1336,

Published: 03 August 2022


Causal loop diagrams (CLDs) are a systems thinking method that can be used to visualize and unpack complex health system behaviour. They can be employed prospectively or retrospectively to identify the mechanisms and consequences of policies or interventions designed to strengthen health systems and inform discussion with policymakers and stakeholders on actions that may alleviate sub-optimal outcomes. Whilst the use of CLDs in health systems research has generally increased, there is still limited use in low- and middle-income settings. In addition to their suitability for evaluating complex systems, CLDs can be developed where opportunities for primary data collection may be limited (such as in humanitarian or conflict settings) and instead be formulated using secondary data, published or grey literature, health surveys/reports and policy documents. The purpose of this paper is to provide a step-by-step guide for designing a health system research study that uses CLDs as their chosen research method, with particular attention to issues of relevance to research in low- and middle-income countries (LMICs). The guidance draws on examples from the LMIC literature and authors’ own experience of using CLDs in this research area. This paper guides researchers in addressing the following four questions in the study design process; (1) What is the scope of this research? (2) What data do I need to collect or source? (3) What is my chosen method for CLD development? (4) How will I validate the CLD? In providing supporting information to readers on avenues for addressing these key design questions, authors hope to promote CLDs for wider use by health system researchers working in LMICs.

COMMENT (NPW): I think this systems-thinking approach could be very helpful to implement Collaboration Area #2 of our HIFA-WHO Collaboration Plan: To support WHO’s work on further understanding and addressing the healthcare information needs of the public, health workers and policymakers.

HIFA itself is based on a systems-thinking approach described in a paper in The Lancet in 2004: Can we achieve health information for all by 2015? The paper notes: 'The development of reliable, relevant, usable information can be represented as a system that requires cooperation among a wide range of professionals including health-care providers, policy makers, researchers, publishers, information professionals, indexers, and systematic reviewers. The system is not working because it is poorly understood, unmanaged, and under-resourced.'

HIFA's role has been largely to support multidisciplinary communication, understanding and advocacy around how to improve the availability and use of reliable healthcare information. Our challenge now is to synthesise the learning from our forums, publications and achievements - together with that from WHO and our supporting organisations - to build a pragmatic picture of drivers and barriers, including causal loop diagrams.

Collaboration Area #2 is the largest of the five areas of collaboration described in the plan. The next step would be to develop a funding proposal for the work. We currently have no funding but we have key strengths: more than 10 years of shared experience and expertise on the forums; a working prototype (HIFA Voices 2.0) to collate and organise these inputs; and forward-looking access to multistakeholder inputs through dynamic discussion. If you feel you can help, please let me know:

Best wishes, Neil

Joint Coordinator, HIFA-WHO Collaboration Group

Let's build a future where every person has access to reliable healthcare information and is protected from misinformation - Join HIFA:

HIFA profile: Neil Pakenham-Walsh is coordinator of the HIFA global health movement (Healthcare Information For All - ), a global community with more than 20,000 members in 180 countries, interacting on six global forums in four languages in collaboration with WHO. HIFA brings stakeholders together to accelerate progress towards universal access to reliable healthcare information. HIFA is administered by Global Healthcare Information Network, a UK based non-profit in official relations with the World Health Organization.

Twitter: @hifa_org neil AT