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.

Causal loop diagrams (CLDs) are a systems thinking method that can be used to visualize and unpack complex health system behaviour. They can be employed prospectively or retrospectively to identify the mechanisms and consequences of policies or interventions designed to strengthen health systems and inform discussion with policymakers and stakeholders on actions that may alleviate sub-optimal outcomes. Whilst the use of CLDs in health systems research has generally increased, there is still limited use in low- and middle-income settings. In addition to their suitability for evaluating complex systems, CLDs can be developed where opportunities for primary data collection may be limited (such as in humanitarian or conflict settings) and instead be formulated using secondary data, published or grey literature, health surveys/reports and policy documents. The purpose of this paper is to provide a step-by-step guide for designing a health system research study that uses CLDs as their chosen research method, with particular attention to issues of relevance to research in low- and middle-income countries (LMICs). The guidance draws on examples from the LMIC literature and authors’ own experience of using CLDs in this research area. This paper guides researchers in addressing the following four questions in the study design process; (1) What is the scope of this research? (2) What data do I need to collect or source? (3) What is my chosen method for CLD development? (4) How will I validate the CLD? In providing supporting information to readers on avenues for addressing these key design questions, authors hope to promote CLDs for wider use by health system researchers working in LMICs.

The most recent reports on global trends in neonatal mortality continue to show alarmingly slow progress on improvements in neonatal mortality rates, with sub-Saharan Africa still lagging behind. This emphasised the urgent need to innovatively employ alternative solutions that take into account the intricate complexities of neonatal health and the health systems in which the various strategies operate. In our first paper, we empirically explored the causes of the stagnating neonatal mortality in Uganda using a dynamic synthesis methodology (DSM) approach. In this paper, we completed the last three stages of DSM, which involved the development of a quantitative (simulation) model, using STELLA modelling software. We used statistical data to populate the model. Through brainstorming sessions with stakeholders, iterations to test and validate the model were undertaken. The different strategies and policy interventions that could possibly lower neonatal mortality rates were tested using what-if analysis. Sensitivity analysis was used to determine the strategies that could have a great impact on neonatal mortality. We developed a neonatal health simulation model (NEOSIM) to explore potential interventions that could possibly improve neonatal health within a health system context. The model has four sectors, namely population, demand for services, health of the mothers and choices of clinical care. It tests the effects of various interventions validated by a number of Ugandan health practitioners, including health education campaigns, free delivery kits, motorcycle coupons, kangaroo mother care, improving neonatal resuscitation and labour management skills, and interventions to improve the mothers health, i.e. targeting malaria, anaemia and tetanus. Among the tested interventions, the package with the highest impact on reducing neonatal mortality rates was a combination of the free delivery kits in a setting where delivery services were free and motorcycle coupons to take women to hospital during emergencies. This study presents a System Dynamics model with a broad and integrated view of the neonatal health system facilitating a deeper understanding of its current state and constraints and how these can be mitigated. A tool with a user friendly interface presents the dynamic nature of the model using ‘what-if’ scenarios, thus enabling health practitioners to discuss the consequences or effects of various decisions. Key findings of the research show that proposed interventions and their impact can be tested through simulation experiments thereby generating policies and interventions with the highest impact for improved healthcare service delivery.

Currently, the adoption and use of social media is widespread in various sectors, including retail businesses. However, new policies significantly affect the adoption of social media and its associated benefit. This research draws from attitude as a determining factor to understand the retail business owners' perception of social media tax in Uganda. Using qualitative methods, data were collected from 183 retail businesses in urban communities. The study established that social media is being used to promote businesses, with WhatsApp, Facebook, and Twitter as the most popular tools. Results further indicate that most retailers see social media platforms as a means of keeping them competitive and urging them to stay connected on these platforms. The study, however, demonstrates that the introduction of social media tax (SMT) changed the behavior of retailers resulting in the reduced use of social media as they thought it was expensive. Further research should seek to investigate (a) the effect of social media tax in financial terms and productivity in retail businesses; (b) the cost–benefit analysis for those paying social media tax; and (c) key factors that could further explain the behavior of retail business owners and the payment of social media tax.

Simplistic representations of traffic safety disregard the dynamic interactions between the components of the road transport system (RTS). The resultant road accident (RA) preventive measures are consequently focused almost solely on individual/team failures at the sharp end of the RTS (mainly the road users). The RTS is complex and therefore cannot be easily understood by studying the system parts in isolation. The study modeled the occurrence of road accidents in Uganda using the dynamic synthesis methodology (DSM). This article presents the work done in the first three stages of the DSM. Data was collected from various stakeholders including road users, traffic police officers, road users, and road constructors. The study focused on RA prevention by considering the linear and non-linear interactions of the variables during the pre-crash phase. Qualitative models were developed and from these, key leverage points that could possibly lower the road accident incidences demonstrating the need for a shared system wide responsibility for road safety at all levels are suggested.

There has been low adherence of antenatal care utilization (ANC) in low and middle-income countries (LMIC) despite its associated negative outcome on women and their unborn babies. Although several studies have examined ANC, the majority focus on isolated aspects and do not explore the holistic approach to understand its dynamics. The system dynamics approach provides a deeper understanding of the phenomenon by examining the underlying factors, causes, effects, feedback, and delays. This study aimed at understanding factors that influence ANC utilization using the system's dynamics approach. An interpretive systematic review to establish multifaceted and context-specific processes was done between May and November 2019. Data from 24 articles were synthesized and used to build causal loop diagrams, which were validated through focus group discussions and interviews with stakeholders. Results revealed human resource numbers and welfare, awareness campaigns, peer support groups, and community-based engagement as key leverage points towards ANC improvement.