title: Application of systems thinking: 12-month postintervention evaluation of a complex health system intervention in Zambia: the case of the BHOMA.
abstract: OBJECTIVE
  Strong health systems are said to be paramount to achieving effective and equitable health care. The World Health Organization has been advocating for using system-wide approaches such as 'systems thinking' to guide intervention design and evaluation. In this paper we report the system-wide effects of a complex health system intervention in Zambia known as Better Health Outcome through Mentorship and Assessment (BHOMA) that aimed to improve service quality.
  
  
  METHODS
  We conducted a qualitative study in three target districts. We used a systems thinking conceptual framework to guide the analysis focusing on intended and unintended consequences of the intervention. NVivo version 10 was used for data analysis.
  
  
  RESULTS
  The addressed community responded positively to the BHOMA intervention. The indications were that in the short term there was increased demand for services but the health worker capacity was not severely affected. This means that the prediction that service demand would increase with implementation of BHOMA was correct and the workload also increased, but the help of clinic lay supporters meant that some of the work of clinicians was transferred to these lay workers. However, from a systems perspective, unintended consequences also occurred during the implementation of the BHOMA.
  
  
  CONCLUSIONS
  We applied an innovative approach to evaluate a complex intervention in low-income settings, exploring empirically how systems thinking can be applied in the context of health system strengthening. Although the intervention had some positive outcomes by employing system-wide approaches, we also noted unintended consequences.
authors.affiliation: Department of Community Medicine, University of Zambia School of Medicine, Lusaka, Zambia.|Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Wilbroad
authors.initials: W
authors.lastname: Mutale
authors.affiliation: Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.|ZAMBART Project, Ridgeway Campus, University of Zambia, Lusaka, Zambia.
authors.forename: Helen
authors.initials: H
authors.lastname: Ayles
authors.affiliation: ZAMBART Project, Ridgeway Campus, University of Zambia, Lusaka, Zambia.
authors.forename: Virginia
authors.initials: V
authors.lastname: Bond
authors.affiliation: Centre for Infectious Disease Control in Zambia, Northmead Lusaka, Zambia.
authors.forename: Namwinga
authors.initials: N
authors.lastname: Chintu
authors.affiliation: Centre for Infectious Disease Control in Zambia, Northmead Lusaka, Zambia.
authors.forename: Roma
authors.initials: R
authors.lastname: Chilengi
authors.affiliation: ZAMBART Project, Ridgeway Campus, University of Zambia, Lusaka, Zambia.
authors.forename: Margaret Tembo
authors.initials: MT
authors.lastname: Mwanamwenge
authors.affiliation: Centre for Infectious Disease Control in Zambia, Northmead Lusaka, Zambia.
authors.forename: Angela
authors.initials: A
authors.lastname: Taylor
authors.affiliation: Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Neil
authors.initials: N
authors.lastname: Spicer
authors.affiliation: Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Dina
authors.initials: D
authors.lastname: Balabanova
mesh_terms: D003150:Community Health Workers / Q000193:education / Q000458:organization & administration*; D003256:Community Participation / Q000379:methods; D003695:Delivery of Health Care / Q000458:organization & administration* / Q000592:standards; D015658:HIV Infections / Q000175:diagnosis / Q000628:therapy; D007722:Health Knowledge, Attitudes, Practice; D006301:Health Services Needs and Demand; D006801:Humans; D007318:Inservice Training; D008499:Medical Records / Q000592:standards; D011203:Poverty; D036301:Qualitative Research; D058996:Quality Improvement / Q000458:organization & administration* / Q000592:standards; D012017:Referral and Consultation / Q000458:organization & administration; D013597:Systems Analysis; D014218:Triage / Q000592:standards; D015024:Zambia
keywords: evaluation; health policy; health services research