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Introduction to Complex Health Systems

Introduction to complex health

systems: wrap-up

Story of the week

from health programmes and services

tohealth systems and

health systems development

tocomplex adaptive health systems and

leading change within them

Understanding systems

The Martian view = the helicopter view, seeing the complex interactions amongst the building blocks and dimensions; to think about design

The Gorilla view = recognising mindsets and the other intangibles;

to think about navigation

Threshold concepts• People make sense of the system around them and act based on

their understandings and mind sets.• Health systems are socially constructed; they exist within contexts

and histories.• Health systems are integrative by nature, and consist of complex

inter-relationships; we all have a role in the system.• Health systems consist of ‘hardware’ and ‘software’.• Health system effectiveness is a ‘whole system’ judgement rather

than one based on the effectiveness of specific interventions. • Power is everywhere: in agency, service delivery and decision-

making.• Everyone has a part to play in the system, working towards shared

goals.• The health system is knowable and changeable.• The health system is a complex adaptive system.

Spot the complexity concept

• Self-organising• History

dependent• Feedback loops• Emergence• Sensemaking• Tipping points• Non-linear

• Interestingly, not power (but is important)

Paper review: core ideas?

Rwashana et al

Blanchet Gilson et al

Using causal loop diagrams to understand an immunization programme as a system

Understanding social networks among agent as central features of systems and their dynamics

Recognising sensemaking as a leadership practice – and that PHC requires collective mindset shifts towards population health & SDH

Four forms of complexity

• Systemic complexity, shaped by feedback, interdependence, interactions

• Behavioural complexity – focus on thinking, behaviour, individuals & groups

• Relational complexity, relationships between people, ideas, entities & networks

• Dynamic complexity and processes, how change actually happens – non-linearity, surprise , tipping points

Ben Ramalingam

Four revolutions

“There are four revolutions currently underway that will transform health and health systems.

These are:

Life sciences

Information and communication technology

Social justice and equity; and

Systems thinking to transcend complexity”

Julio Frenk (2008) Acknowledging the past, Committing to the future.

Systems thinking

Systems thinking gives deeper insights into: how a system works,

– why it has problems, – how it can be improved

Graphic adapted from Ahn A.C. et al. PLoS Med 3:956-960 (2006).

Small changes can produce big results-- but points of highest leverage are least obvious

There are no rules for finding tipping points, but there are ways of thinking

that make it more likely.

Learning to look system-wide and see underlying

“processes and approaches” rather than

"events" is a starting point...

Leverage points when intervening in a system

(in increasing order of effectiveness)

9. Constants, parameters, numbers, subsidies8. Regulating negative feedback loops7. Driving positive feedback loops6. Material flows5. Information flows4. Rules of the system (incentives, constraints)3. Distribution of power over the rules of the system2. Goals of the system1. The mindset or paradigm out of which the system – its goals, power structure, rules, culture arises.

Modified from Donella Meadows

Leadership for complexity

1. Shared sensemaking > collective mindsets to support change

2. Creating connection > relationships that enable change

3. Navigation > learning from innovation & emergent strategies

Drath 2003

Systems thinking involves shifting attention…

from the parts to the whole,  from objects to relationships,  from structures to processes,  from hierarchies to networks, from the rational to the intuitive,  from analysis to synthesis,  from linear to non-linear thinking.

Adapted from Fritjof Capra

A different way of thinking

Command & control thinking

Systems thinking

Perspective Top-down hierarchy Outside-in

Design Functional Demand, value, flow

Design-making Separated from work Integrated with work

Measurement Output related to budget Capability related to purpose

Attitude to clients Contractual What matters?

Attitude to providers Contractual Cooperative

Management role People and budgets Act on the system

Ethos Control Learning

Change Reactive, projects Adaptive, integral

Motivation Extrinsic Intrinsic

De Savigny and Adams, 2009

System thinking skillsUsual approach Systems thinking approach

Static thinking Dynamic thinking

focus on events focus on patterns of behaviour

System thinking skillsUsual approach Systems thinking approach

Static thinking Dynamic thinking

focus on events focus on patterns of behaviour

Systems as effect Systems as cause

behaviour as externally driven responsibility for behaviour from internal actors and rules

System thinking skillsUsual approach Systems thinking approach

Static thinking Dynamic thinking

focus on events focus on patterns of behaviour

Systems as effect Systems as cause

behaviour as externally driven responsibility for behaviour from internal actors and rules

Tree-by-tree thinking Forest-thinking

knowledge from understanding details knowledge from understanding contexts of relationships

System thinking skillsUsual approach Systems thinking approach

Static thinking Dynamic thinking

focus on events focus on patterns of behaviour

Systems as effect Systems as cause

behaviour as externally driven responsibility for behaviour from internal actors and rules

Tree-by-tree thinking Forest-thinking

knowledge from understanding details knowledge from understanding contexts of relationships

Factors thinking Operational thinking

concentrating on factors that influence or correlate

concentrating on causality and how behaviour is generated

System thinking skillsUsual approach Systems thinking approach

Static thinking Dynamic thinking

focus on events focus on patterns of behaviour

Systems as effect Systems as cause

behaviour as externally driven responsibility for behaviour from internal actors and rules

Tree-by-tree thinking Forest-thinking

knowledge from understanding details knowledge from understanding contexts of relationships

Factors thinking Operational thinking

concentrating on factors that influence or correlate

concentrating on causality and how behaviour is generated

Linear thinking Loop thinking

view causality running in one direction View causality as an on-going process with feedback influencing causes

Systems thinkingSolving Today's Problems

Many of the local and global challenges facing us today are embedded in interconnected

systems. Addressing these challenges means moving beyond the limitations of the perspectives,

methods and tools of traditional reductionistic science.

"... systems thinking is based on the fundamental shift of perception from the world as a machine to the world as a

living system.“

Fritjof Capra

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Introduction to Complex Health Systems, Presentation 8. Copyright CHEPSAA (Consortium for Health Policy & Systems Analysis in Africa) 2014, www.hpsa-africa.org www.slideshare.net/hpsa_africa

This document is an output from a project funded by the European Commission (EC) FP7-Africa (Grant no. 265482). The views expressed are not necessarily those of the EC.

The CHEPSAA partners

University of Dar Es SalaamInstitute of Development Studies

University of the WitwatersrandCentre for Health Policy

University of GhanaSchool of Public Health, Department of Health Policy, Planning and Management

University of LeedsNuffield Centre for International Health and Development

University of Nigeria Enugu Health Policy Research Group & the Department of Health Administration and Management

London School of Hygiene and Tropical MedicineHealth Economics and Systems Analysis Group, Depart of Global Health & Dev.

Great Lakes University of KisumuTropical Institute of Community Health and Development

Karolinska InstitutetHealth Systems and Policy Group, Department of Public Health Sciences

University of Cape TownHealth Policy and Systems Programme, Health Economics Unit

Swiss Tropical and Public Health InstituteHealth Systems Research Group

University of the Western CapeSchool of Public Health