title: Advancing the application of systems thinking in health: understanding the dynamics of neonatal mortality in Uganda.
abstract: BACKGROUND
  Of the three million newborns that die each year, Uganda ranks fifth highest in neonatal mortality rates, with 43,000 neonatal deaths each year. Despite child survival and safe motherhood programmes towards reducing child mortality, insufficient attention has been given to this critical first month of life. There is urgent need to innovatively employ alternative solutions that take into account the intricate complexities of neonatal health and the health systems. In this paper, we set out to empirically contribute to understanding the causes of the stagnating neonatal mortality by applying a systems thinking approach to explore the dynamics arising from the neonatal health complexity and non-linearity and its interplay with health systems factors, using Uganda as a case study.
  
  
  METHODS
  Literature reviews and interviews were conducted in two divisions of Kampala district with high neonatal mortality rates with mothers at antenatal clinics and at home, village health workers, community leaders, healthcare decision and policy makers, and frontline health workers from both public and private health facilities. Data analysis and brainstorming sessions were used to develop causal loop diagrams (CLDs) depicting the causes of neonatal mortality, which were validated by local and international stakeholders.
  
  
  RESULTS
  We developed two CLDs for demand and supply side issues, depicting the range of factors associated with neonatal mortality such as maternal health, level of awareness of maternal and newborn health, and availability and quality of health services, among others. Further, the reinforcing and balancing feedback loops that resulted from this complexity were also examined. The potential high leverage points include special gender considerations to ensure that girls receive essential education, thereby increasing maternal literacy rates, improved socioeconomic status enabling mothers to keep healthy and utilise health services, improved supervision, and internal audits at the health facilities as well as addressing the gaps in resources (human, logistics, and drugs).
  
  
  CONCLUSIONS
  Synthesis of theoretical concepts through CLDs facilitated our understanding and interpretation of the interactions and feedback loops that contributed to the stagnant neonatal mortality rates in Uganda, which is the first step towards discussing and exploring the potential strategies and their likely impact.
authors.affiliation: Information Systems Department, College of Computing and Information Sciences, Makerere University, P,O, Box 7062, Kampala, Uganda. asemwanga@cit.ac.ug.
authors.forename: Agnes Semwanga
authors.initials: AS
authors.lastname: Rwashana
authors.forename: Sarah
authors.initials: S
authors.lastname: Nakubulwa
authors.forename: Margaret
authors.initials: M
authors.lastname: Nakakeeto-Kijjambu
authors.forename: Taghreed
authors.initials: T
authors.lastname: Adam
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D003695:Delivery of Health Care; D005260:Female; D057220:Health Literacy; D006295:Health Resources; D006801:Humans; D007223:Infant; D007226:Infant Mortality; D007231:Infant, Newborn; D008427:Maternal Health Services; D008429:Maternal Welfare; D011247:Pregnancy; D012959:Socioeconomic Factors; D014454:Uganda / Q000453:epidemiology; D055815:Young Adult
references.citation: Health Policy Plan. 2007 Mar;22(2):95-102
references.pmid: 17299023
references.citation: BMJ. 2008 Jun 7;336(7656):1281-3
references.pmid: 18535071
references.citation: Health Informatics J. 2009 Jun;15(2):95-107
references.pmid: 19474223
references.citation: Reprod Health. 2010 Nov 05;7:30
references.pmid: 21054870
references.citation: Health Policy. 2011 Mar;99(3):226-33
references.pmid: 21071106
references.citation: PLoS Med. 2013;10(1):e1001373
references.pmid: 23349622
references.citation: Soc Sci Med. 2013 Sep;93:220-8
references.pmid: 23103350