Informing ICD-11 implementation: applying systems thinking to assess mortality information systems in Ecuador and Trinidad and Tobago

<title>ABSTRACT</title> <sec> <title>Objectives.</title> 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. </sec> <sec> <title>Methods.</title> 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. </sec> <sec> <title>Results.</title> 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. </sec> <sec> <title>Conclusions.</title> 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. </sec>