An international study has called for more focus on the way entire health systems work together after findings revealed how well-intentioned changes can backfire, making patient outcomes worse.
Conversely, some changes can deliver benefits that extend well beyond their original scope. But among several possible interventions, enhancing trust in the healthcare system was perceived as having the greatest impact on clinical outcomes.
Published in BMJ Global Health, the research found almost 1,000 interconnected factors that influence patient survival after injury in low and middle-income countries, which account for around 85% of injury-related deaths worldwide.
As one of the first studies to capture the full complexity of a health system delivering injury care, the global team, involved a collaboration led between University of Birmingham, with partners from the University of Stellenbosch, Nottingham Business School (NBS), part of Nottingham Trent University, the University of York, and the University of Aberdeen.
The investigators mapped how patients move through care, from seeking and reaching help, to receiving treatment, and remaining in care for recovery.
Rather than focusing on single interventions or outcomes, the research analysed interactions which span multiple pathways of care and their interactions. This included considering patient and community factors, such as beliefs, ability to pay, and trust; health service factors, including quality of care, staffing, and funding; and wider societal context, such as poverty, infrastructure, and policy.
Findings highlight that health systems are highly complex and interconnected, which means that improving one part can unintentionally create pressure elsewhere.
Dr Lucia D’Ambruoso, Senior Lecturer at the University of Aberdeen, led a related piece of work supported by the same programme which was published in Critical Public Health, said: “Injuries kill six million people every year, and the vast majority happen in low and middle-income countries where health systems are already under enormous pressure.
“What this work shows is that the data we routinely collect such as admissions, procedures, and deaths only ever captures a fraction of what's actually going on. The structural conditions that drive injury risk and stop people getting care almost never show up in the numbers. By applying critical realist thinking, we can treat routine data as a starting point for asking deeper questions: ‘who is missing from the picture, and why?’ That shift, from counting to understanding, is fundamental for broad policy traction.”
Senior author of the study, Antuela Tako, Professor of Operations Research at NBS, said: “We found that patient trust, perceptions of care quality, and people’s willingness to seek treatment were among the most influential factors shaping outcomes.
“However, addressing these factors in isolation is not enough. For example, increasing trust can encourage more people to seek care earlier, improving recovery and reducing mortality and disability.
Lead author, Justine Davies, Professor of Global Health Research at the University of Birmingham, said, “Our work also clearly shows that improving care results in increased demand on the health system. However, that must be matched by greater capacity and higher-quality services, to prevent health systems becoming overwhelmed by the increased demand. Increased demand quickly can lead to delays, reduced quality of care, and declining trust, ultimately undermining the very improvements those changes were intended to achieve.”
The research instead calls for a fundamental shift in how health systems are understood and strengthened through multi-sector approaches, linking health policy with investments in workforce capacity, transport, education, communities, and economic development.
Kathryn Chu, Professor of Global Surgery at Stellenbosch University, added: “Conventional approaches are insufficient to deliver sustained improvement. Things can only be truly improved through a whole-system approach that consider wider social and economic factors and places patient trust, system design and equity at the centre of reform.”
The research involved researchers from the UK and South Africa and was supported by a prestigious two-month residential team fellowship awarded by the Stellenbosch Institute of Advanced Studies (STIAS) to Professor Justine Davies, Professor Kathryn Chu, Dr Lucia D’Ambruoso, Professor Laura Bojke and Professor Antuela Tako.
The research A systems approach to understand injury care in LMICs using causal loop diagrams had been published in BMJ Global Health.