title: Complexity methods for understanding global health governance, financing and delivery arrangements - from system-wide dynamics to neglected tropical disease control in Uganda
Creators: name: Fergus, Cristin Alexis
Publisher: name: London School of Economics and Political Science (LSE)
Year: 2022

description: This thesis aims to understand how methodological and conceptual approaches to complexity in quantitative analysis can improve evidence and decision-making, specifically for schistosomiasis control in Uganda and more broadly within global health. Engaging directly with the complexity through methodological choices provided new insights into policies and practices in global health. In Paper 1, I provided an overview of actors and power dynamics in global health, by describing the changing landscape of global health actors as it relates to relative shifts in power over time. This is accomplished by capturing the emergent, dynamic network structure of development aid for health in the period encompassing the ‘MDG era’, between 1990 and 2015. This paper was published in the Journal of Health Policy and Planning (https://doi.org/10.1093/heapol/czac025). Paper 2 aimed to develop evidence for decision-making in response to the needs of policymakers and practitioners, with a focus on schistosomiasis transmission and control activities in Uganda. This was accomplished by (1) capturing the perspectives of national and sub-national decision-makers on schistosomiasis transmission using participatory modelling, and (2) using the participatory modelling outputs to inform mathematical model simulations in response to the evidence needs. The implementation of this approach challenged the balance of power between international and domestic actors in the development of evidence and decisions regarding the delivery of global health interventions. This paper was published in BMJ Global Health (http://dx.doi.org/10.1136/bmjgh-2021-007113). Paper 3 used the outcomes of the participatory systems mapping workshops and individual-based simulations to guide the scope and content of economic evaluations of schistosomiasis interventions. The results indicated that the most cost-effective scenario is a system of implementation reliant on volunteers from within communities and donated drugs. As anticipated, when all else is held equal, including these costs result in lower cost-effectiveness ratios relative to other interventions. Further, the results bring into question the purpose of continuing interventions which are not predicted to achieve the desired targets within the 30-year time horizon. This paper highlighted potential opportunities for schistosomiasis intervention design and implementation which is more aligned with the aims of equitable, country-led sustainable development. Paper 4 shifted the focus within the discussion of evidence for decision-making in global health to consider one particular type, peer-reviewed publications, which is most often considered as ‘best practice’ in evidence-based decision-making. A systematic review captured the network of authors who had published on MDA. These results constituted the sampling frame for a remote survey to elucidate perspectives on their roles in policy and practice related to MDA. The findings highlighted the ongoing structural disparities in research leadership and found broad concern about opportunities and about disconnects that limit engagement between researchers and decision-makers for use of primary research in policy and decision-making processes. Paper 4 was published in the Journal of Public Health Policy (https://doi.org/10.1057/s41271-021-00294-x). Broadly speaking, the papers in this thesis have shown that while reductionist, linear perspectives may be part of the reason for the continuation of ineffectual policies and practices, the confluence of politics, power relations, and economies in the context of a complex system of actors and processes also plays a significant role with regards to policy and practice decision making. This was observed in relation to schistosomiasis in Uganda and more broadly in global health at the system level. This thesis uses language and methods common in health sciences to communicate critiques in a way that can be engaged with by health policy-makers, practitioners, and many public health researchers. Finally, this thesis showed the possibilities for using network-based and computational models for understanding complexity within the global health 'system'.