A Complex Systems Approach to Modelling Oral Health Service Delivery Failures in Northern Nigerian States

Oral health service delivery failures in northern Nigeria reflect complex adaptive system dynamics including feedback loops between workforce distribution, patient demand, financing, and community health literacy that resist simple linear policy interventions, and modelling these dynamics provides original methodological and policy contributions. This study developed and applied a complex systems model of oral health service delivery failure in four northern Nigerian states: Kano, Borno, Zamfara, and Niger. A complexity science methodology was employed, combining causal loop diagram development through expert facilitated group model building with 40 stakeholders including dental officers, health planners, community members, and policy researchers, agent-based simulation modelling, and system archetype analysis. The causal loop diagram identified 48 variables and 73 causal relationships, with four reinforcing feedback loops sustaining service delivery failure: the trained dentist-out-migration loop, the low-demand-low-investment loop, the informal practitioner substitution loop, and the health literacy-service trust deficit loop. Agent-based simulations tested 12 intervention scenarios. Simultaneous investment in workforce retention and demand generation achieved the greatest service access improvement (34.7 percent increase in model). Single-intervention workforce deployment increased service provision but did not improve long-term sustainability due to unchanged demand patterns. The original Complex Systems Oral Health Service Model for Northern Nigeria constitutes a methodological and theoretical contribution. Expert review confirmed model validity. Recommendations include a state-level participatory system mapping process as the foundation for any oral health service reform initiative.

Keywords: complex systems, oral health service delivery, northern Nigeria, agent-based model, causal loop diagram