Systems thinking in practice when implementing a national policy program for the improvement of women's healthcare.

Introduction: Interest in applying systems thinking (ST) in public health and healthcare improvement has increased in the past decade, but its practical use is still unclear. ST has been found useful in addressing the complexity and dynamics of organizations and welfare systems during periods of change. Exploring how ST is used in practice in national policy programs addressing complex and ill-structured problems can increase the knowledge of the use and eventually the usefulness of ST during complex changes. In ST, a multi-level approach is suggested to coordinate interventions over individual, organizational, and community levels, but most attempts to operationalize ST focus on the individual level. This study aimed to investigate how ST is expressed in policy programs addressing wicked problems and describe the specific action strategies used in practice in a national program in Sweden, using a new conceptual framework comprising ST principles on the organizational level as an analytical tool. The program addresses several challenges and aims to achieve systems change within women's healthcare. Methods: The case study used a rich set of qualitative, longitudinal data on individual, group, and organizational levels, collected during the implementation of the program. Deductive content analysis provided narrative descriptions of how the ST principles were expressed in actions, based on interviews, observations, and archival data. Results: The results showed that the program management team used various strategies and activities corresponding to organizational level ST. The team convened numerous types of actors and used collaborative approaches and many different information sources in striving to create a joint and holistic understanding of the program and its context. Visualization tools and adaptive approaches were used to support regional contact persons and staff in their development work. Efforts were made to identify high-leverage solutions to problems influencing the quality and coordination of care before, during, and after childbirth, solutions adaptable to regional conditions. Discussion/conclusions: The organizational level ST framework was useful for identifying ST in practice in the policy program, but to increase further understanding of how ST is applied within policy programs, we suggest a multi-dimensional model to identify ST on several levels.