John Pastor Ansah: “How can models help us understand the complexity we are living in?”

John P. Ansah, PhD

We are delighted to welcome John Pastor Ansah, PhD to Cleveland and the CHI Center team. John’s research uses systems thinking, system dynamics, and computational modeling to understand complex health system issues and inform policy and interventions to improve health. His work also incorporates group model building and significant stakeholder participation. John’s path has taken him from his home in Ghana to graduate studies in Norway and Canada. Most recently, he was on faculty at Duke-NUS in Singapore.  

 

Q: Do you call yourself a health services researcher?

A: I consider myself somebody who has been using systems models to understand health services issues. I focus on using simulation modeling to improve policy decisions. That’s the space I’ve been working in for the last 10 years.

Q: Was there a certain experience or person that got you started on that path?

A: My PhD had to do with learning to use models to improve decisions. It was in economics, public finance, looking at how countries borrow money and how the monies are used to improve development and how they are paid back. A country borrows money to invest, but if the money doesn’t create enough GDP [gross domestic product] or taxes to pay it back, the country is in a debt trap. I looked at policies to improve that.

The application to health really happened after my PhD, when I started work in Singapore [in 2010]. I was in the Health Services department working with David Matchar. We created a research group that focuses on the use of systems models to help improve policy.

Q: So you’ve looked at other complex systems, in addition to healthcare.

A: Yes. Something that was really interesting for me was when I was about to finish my PhD. I was contracted to build a model to help the United Nations Environment Programme look at the benefits of investing in green economies in terms of improving the environment, creating jobs, and creating green wealth. I had to engage a lot of high-level policy individuals, create a model, and produce a report for the UNEP work. That was where my interest really developed. It was practical at a higher level, but the models were extremely complicated.

Q: Did you have any idea when you first went to college that this is the direction you would go?

A: No. I was very convinced that I did not want to end up in academia! But I found this was something that I really enjoyed doing. In Singapore, we were able to combine our work with direct engagement with policymakers. We traveled a lot to try to understand the issues that they are struggling with and how modeling can help them. I also trained policymakers and analysts from health ministries in Thailand, the Philippines, Cambodia, and Singapore to help them understand some of the complexities that they are dealing with and how they can use models to improve some of their decisions. That’s been quite fulfilling.

Q: It sounds like stakeholder participation is an important part of your work.

A: Yes, we’ve done a lot of stakeholder participation. I’ve also taught students how to do modeling and how to engage stakeholders in models. We’ve organized different workshops and programs where people from different countries come together. Right now we are training policymakers and analysts across Malaysia, the Philippines, and Thailand in systems modeling and use of real-world evidence to improve policy.

Q: You’ve lived in several different places, all with different health care systems: Ghana, Norway, Singapore. Have those global influences shaped your work?

A: Yes, in many ways. In Singapore, we had students from everywhere - China, Malaysia, the Philippines - so in my class we always talked about different healthcare systems. Also, in training we engaged policymakers from different countries, so differences in healthcare systems always came up. Singapore’s healthcare system is very different from many other countries in the world, so contrasting it with other countries is something that we always discussed.

Q: Have these influences changed the work that you’re doing right now?

A: Yes. It really helps to understand how different people are looking at policies differently and the context that people are living in. Healthcare these days has become a very controversial area because of financing and mental models, how people perceive health care. All this influences the way that you look at health care and the way you approach and contextualize it.

One thing I’m trying to do now is understand the US healthcare system. The problem for me is that

I always ask myself, who has the power to make change? In Singapore it’s very easy. You can identify the individuals. You can go to them; I’ve presented to the Minister of Health many times. You can pitch an idea and have a discussion with them and ask questions. If they want to, they can make changes. The question in the US healthcare system is, where does change happen?

Q: That’s a great question. Our healthcare system is run for profit, and there’s a lot of power tied up in that.

A: That’s interesting. In Singapore, 80% of the hospitals are public hospitals, the other 20% are private. That means the government makes money from the healthcare system and the money is reinvested to support those who can’t afford it. So basically, it’s like taking money from the left hand and giving to the right hand. The profit doesn’t go to individuals, it comes to the state to reduce prices and give more subsidies and support the poor. So they are able to control the system. There is a national health account. The government knows every individual in the country, how much money they have in their account for health. They can easily identify those who need support because they cannot afford it. It’s very very different.

Q: It really is. You’ve also done some work in primary care, right?

A: My primary care work [in Singapore] is ongoing. They are trying very hard to change the healthcare system on a primary care level. The primary care that was developed previously was basically for acute conditions. Now, most of the population is living longer with chronic conditions. Primary care doesn’t have systems in place for continuous care provision, so they are trying to reorganize it.

Q: What are some of your other areas of interest?

A: I’ve done work looking at aging and long-term care issues. In Singapore, the government provides very little nursing home type care, so most individuals with long term care needs are supposed to stay at home with their families. The birth rate is low, and the family size is very small, so there is an increasing burden on families to provide care for their elderly who are living much longer with limitations. We are trying to understand what the demands are going to be in the future, how they can improve community-based care and support these families with services in the community.

I’ve also done a lot of work looking at investment in chronic diseases. I’m building a chronic disease model and looking at about 10 chronic diseases, the bigger ones, and looking at risk factors and how different interventions will reduce the incidence and prevalence of some of these conditions and the cost to society. And I’m finishing up work on resilience and recovery, how resilience influences individuals who experience hip fracture.

I have a special interest in workforce planning. I’ve done a lot of work, mainly with folks in the Eye Center [in Singapore], to look at how we can project the future workforce and also to look at task shifting. The question is, how can we redesign tasks so that doctors are free to do the things they are supposed to do.

Q: The topics you’re taking on are big!

A: Our focus has always been on how we influence policy, so we are looking at a higher level.

Q: Now that you’re starting to get a US perspective, are there other things you’d like to look into?

A: Primary care is something that I would like to continue working on. I submitted a grant application to understand the mechanism through which high-value primary care produces value. We also want to look at how these core components of high-value primary care (coordination, integration, access, whole person care) interact to produce population health outcomes. Then I want to look at different combinations of these components. What can we achieve and what are we losing when certain combinations of [primary care] components are present? How do they help us achieve goals like population health, reducing costs, and the experiences of patients and clinicians? There’s a lot of room for developing interventions around this.

In general, since my interest is in modeling and looking at how we can use models to improve understanding of complex systems, my main issue is, how can a model help policy across health care and conditions? How can models help us understand the complexity we are living in, and how can that understanding improve our decision making and our policies and positions?

Another interest I have is teaching. That engagement with students to really understand what they are thinking, not just things that I perceive to be important, is something that I really really cherish. I’m hoping I’ll be able to continue that here.