Informing ICD-11 implementation: applying systems thinking to assess mortality information systems in Ecuador and Trinidad and Tobago; [Fundamentação da implementação da CID-11: aplicação do pensamento sistêmico para avaliar os sistemas de informação sobre mortalidade no Equador e em Trinidad e Tobago]

Tavakkoli M.; Ballester-Otero C.L.; Miki J.; Fruchtman C.S.; Savigny D.; Gerger A.; Joos O.; Hinds A.Q.J.; Becedas R.R.; Kontio K.; Munoz D.C. · Revista Panamericana de Salud Publica/Pan American Journal of Public Health (2025) · DOI: 10.26633/rpsp.2025.109

Resumen

Objectives. To assess challenges and opportunities within the mortality information systems of Ecuador and Trinidad and Tobago to support the implementation of the International Classification of Diseases, 11th revision (ICD-11) coding system. Methods. We applied a qualitative approach using business process mapping, a systems thinking tool that visualizes workflows, stakeholder roles, and information flows. The study had four phases: document review; pre-workshop consultations; development of country-specific process maps; and participatory workshops with stakeholders. Data collection and analysis were conducted between May 2022 and July 2023. Results. The transition to ICD-11 presents complex, system-wide challenges. Analysis of process maps revealed inefficiencies and structural gaps across five key areas: governance and coordination; data capture and standardization; human resources and training; technology and infrastructure; and reporting and dissemination. Both countries face inconsistent use of ICD-10 versions, a shortage of trained coders, reliance on paper-based processes, and limited inter-agency data sharing. However, opportunities also emerged, including strong stakeholder interest, pilot digital initiatives, and regional support through the Pan American Health Organization and Caribbean Public Health Agency. Conclusions. The findings from Ecuador and Trinidad and Tobago illustrate systemic barriers common in mortality data systems transitioning to ICD-11. Overcoming these challenges will require targeted investments in digital infrastructure, improved inter-agency coordination, and workforce development. Applying systems thinking and business process mapping can guide countries in strengthening their mortality surveillance systems and managing ICD-11 implementation effectively.