ICHS 8
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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