Advancing the application of systems thinking in health: advice seeking behavior among primary health care physicians in Pakistan

Malik, Asmat U., Willis, Cameron D., Hamid, Saima, Ulikpan, Anar and Hill, Peter S. (2014) Advancing the application of systems thinking in health: advice seeking behavior among primary health care physicians in Pakistan. Health Research Policy and Systems, 12 43: 1-12. doi:10.1186/1478-4505-12-43

Author Malik, Asmat U.
Willis, Cameron D.
Hamid, Saima
Ulikpan, Anar
Hill, Peter S.
Title Advancing the application of systems thinking in health: advice seeking behavior among primary health care physicians in Pakistan
Journal name Health Research Policy and Systems   Check publisher's open access policy
ISSN 1478-4505
Publication date 2014-08-26
Year available 2014
Sub-type Article (original research)
DOI 10.1186/1478-4505-12-43
Open Access Status DOI
Volume 12
Issue 43
Start page 1
End page 12
Total pages 12
Place of publication London, United Kingdom
Publisher BioMed Central
Language eng
Formatted abstract

Using measles and tuberculosis as case examples, with a systems thinking approach, this study examines the human advice-seeking behavior of primary health care (PHC) physicians in a rural district of Pakistan. This study analyzes the degree to which the existing PHC system supports their access to human advice, and explores in what ways this system might be strengthened to better meet provider needs.


The study was conducted in a rural district of Pakistan and, with a cross-sectional study design, it employed a range of research methods, namely extensive document review for mapping existing information systems, social network analysis of physicians’ advice-seeking practice, and key stakeholder interviews for an in-depth understanding of the experience of physicians. Illustrations were prepared for information flow mechanism, sociographs were generated for analyzing social networks, and content analysis of qualitative findings was carried out for in-depth interpretation of underlying meanings.


The findings of this study reveal that non-availability of competent supervisory staff, a focus on improving performance indicators rather than clinical guidance, and a lack of a functional referral system have collectively created an environment in which PHC physicians have developed their own strategies to overcome these constraints. They are well aware of the human expertise available within and outside the district. However, their advice-seeking behavior was dependent upon existence of informal social interaction with the senior specialists. Despite the limitations of the system, the physicians proactively used their professional linkages to seek advice and also to refer patients to the referral center based on their experience and the facilities that they trusted.


The absence of functional referral systems, limited effective linkages between PHC and higher levels of care, and a focus on programmatic targets rather than clinical care have each contributed to the isolation of physicians and reactive information seeking behavior. The study findings underscore the need for a functional information system comprising context sensitive knowledge management and translation opportunities for physicians working in PHC centers. Such an information system needs to link people and resources in ways that transcend geography and discipline, and that builds on existing expertise, interpersonal relationships, and trust.
Keyword Health system
Primary health care
Social network analysis
Systems thinking
Social network analysis
Information needs
Clinical questions
Q-Index Code C1
Q-Index Status Confirmed Code
Institutional Status UQ

Document type: Journal Article
Sub-type: Article (original research)
Collections: Official 2015 Collection
School of Public Health Publications
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Citation counts: TR Web of Science Citation Count  Cited 7 times in Thomson Reuters Web of Science Article | Citations
Scopus Citation Count Cited 9 times in Scopus Article | Citations
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Created: Thu, 23 Oct 2014, 03:12:03 EST by Associate Professor Peter Hill on behalf of School of Public Health