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A system dynamics approach to health system transformation: a case study of tertiary services provision in the KwaZulu-Natal Department of Health.

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When staff attrition intensifies in a flagship hospital, which has been internationally benchmarked for its best practices, then health care provision is in crisis. Hospital managers are inundated by resource constraints and challenging priorities that make excessive demands on their time, energy, leadership practice, spirit of work and motivation. These leaders are consumed by operational matters such as attending meetings, resolving human resource issues, hospital management and administrative tasks, which leave them with limited time for coordinated strategic planning, monitoring implementation of services or reflection. Consequently, systemic tension exists between policy implementation and service delivery, resulting in escalating patient and staff complaints, dissatisfaction, and medical litigation, thereby producing instability and fluctuations in the health ecosystem organizational behaviour. In examining literature which proposes the value of a systemic approach to organisational behaviour, I decided to embark on this study to apply the qualitative system dynamics (SD) approach and the complexity theory methodology. I explored the dynamic complexities in the KwaZulu Natal (KZN) health ecosystem behaviour, the underlying systemic factors and their inter-relationships, the organisational messiness, and the uncertainties and policy processes that impact on effective service delivery in the one central and three tertiary hospitals. Focus group discussions (FGD) were among the research techniques used, whereby dialogue with participants identified the variables and verified the data collected. These conversations deepened our understanding of the research gap, that is, the sustained shortage of medical specialists over time; the supply and demand of specialists in KZN hospitals, and suggested changes to workforce planning, so as to diffuse these types of tensions within managed systems. While using the SD approach, our rational systems, critical and complexity thinking around issues and simulating circumstances and organisational behaviour; multidimensional social interactions, beliefs and paradigms, all became evident. Feedback loops in causal loop diagrams (CLD) co-constructed with the FG, facilitated our visualizing the ontological context; how the elements interconnect, interact and change over time. The significance of time delays, which cause tensions in policy implementation, governance and decision-making that affect dynamic system behaviour, was apparent. The CLD identified the leverage points for a complex, all-embracing, multi-level approach to organizational transformation. I discovered, through this study, knowledge and skills to effect profound transformation in my awakened leadership practice. This research contributes to emerging literature on applying the SD approach to health care leaders becoming effective and committed to enact integral ethical health care. It recommends paradigmatic deconstruction in reductionist thinking; shifting egocentric consciousness and limiting health care practices; constructing whole systems thinking, integrated participative consciousness, and a transdisciplinary integral team approach, through awakened integral leadership


Doctoral Degree. University of KwaZulu-Natal, Durban.