Applied systems thinking: a viable approach to identify leverage points for accelerating progress towards ending neglected tropical diseases

BACKGROUND: Systems thinking is a conceptual approach that can assist stakeholders in understanding complexity and making progress on persistent public health challenges. Neglected tropical diseases (NTDs), a complex global health problem, are responsible for a large disease burden among impoverished populations around the world. This aim of this study was to better discern the many complexities of the global NTD system in order to identify and act on leverage points to catalyse progress towards ending NTDs. METHODS: Existing frameworks for systems change were adapted to form the conceptual framework for the study. Using a semi-structured interview guide, key informant interviews were conducted with NTD stakeholders at the global level and at the country level in Nigeria. The interview data were coded and analysed to create causal loop diagrams that resulted in a qualitative model of the global NTD system. RESULTS: The complete qualitative model is discussed and presented visually as six separate sub-components that highlight key forces and feedback loops within the global NTD system. CONCLUSIONS: We identified five leverage points for NTD system change, namely (1) clarify the potential for and assess realistic progress towards NTD elimination, (2) increase support for interventions besides drug delivery, (3) reduce dependency on international donors, (4) create a less insular culture within the global NTD community, and (5) systemically address the issue of health worker incentives. The specific findings for NTDs raise a number of uncomfortable questions that have not been addressed, at least in part, because it is easier to continue focusing on ‘quick win’ solutions. The study provides a model of a systems thinking approach that can be applied to other complex global health and development challenges in order to understand complexity and identify leverage points for system change.