Community Health Systems as Complex Adaptive Systems: Ontology and Praxis Lessons from an Urban Health Experience with Demonstrated Sustainability

Existing performance management approaches in health systems in low-income and middle-income countries are generally ineffective at driving organisational-level and population-level outcomes. They are largely directive: they try to control behaviour using targets, performance monitoring, incentives and answerability to hierarchies. In contrast, enabling approaches aim to leverage intrinsic motivation, foster collective responsibility, and empower teams to self-organise and use data for shared sensemaking and decision-making.The current evidence base is too limited to guide reforms to strengthen performance management in a particular context. Further, existing conceptual frameworks are undertheorised and do not consider the complexity of dynamic, multilevel health systems. As a result, they are not able to guide reforms, particularly on the contextually appropriate balance between directive and enabling approaches. This paper presents a framework that attempts to situate performance management within complex adaptive systems. Building on theoretical and empirical literature across disciplines, it identifies interdependencies between organisational performance management, organisational culture and software, system-level performance management, and the system-derived enabling environment. It uses these interdependencies to identify when more directive or enabling approaches may be more appropriate. The framework is intended to help those working to strengthen performance management to achieve greater effectiveness in organisational and system performance. The paper provides insights from the literature and examples of pitfalls and successes to aid this thinking. The complexity of the framework and the interdependencies it describes reinforce that there is no one-size-fits-all blueprint for performance management, and interventions must be carefully calibrated to the health system context.

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A health systems resilience research agenda: moving from concept to practice

BMJ Global Health ◽

10.1136/bmjgh-2021-006779 ◽

2021 ◽

Vol 6 (8) ◽

pp. e006779

Author(s):

Dell D Saulnier ◽

Karl Blanchet ◽

Carmelita Canila ◽

Daniel Cobos Muñoz ◽

Livia Dal Zennaro ◽

...

Keyword(s):

Health System ◽

Health Systems ◽

Complex Adaptive Systems ◽

Adaptive Systems ◽

Dynamic Performance ◽

Performance Outcomes ◽

Theoretical Research ◽

Systems Research ◽

Complex Adaptive ◽

System Resilience

Health system resilience, known as the ability for health systems to absorb, adapt or transform to maintain essential functions when stressed or shocked, has quickly gained popularity following shocks like COVID-19. The concept is relatively new in health policy and systems research and the existing research remains mostly theoretical. Research to date has viewed resilience as an outcome that can be measured through performance outcomes, as an ability of complex adaptive systems that is derived from dynamic behaviour and interactions, or as both. However, there is little congruence on the theory and the existing frameworks have not been widely used, which as diluted the research applications for health system resilience. A global group of health system researchers were convened in March 2021 to discuss and identify priorities for health system resilience research and implementation based on lessons from COVID-19 and other health emergencies. Five research priority areas were identified: (1) measuring and managing systems dynamic performance, (2) the linkages between societal resilience and health system resilience, (3) the effect of governance on the capacity for resilience, (4) creating legitimacy and (5) the influence of the private sector on health system resilience. A key to filling these research gaps will be longitudinal and comparative case studies that use cocreation and coproduction approaches that go beyond researchers to include policy-makers, practitioners and the public.

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Irrational use of antibiotics in Iran from the perspective of complex adaptive systems: redefining the challenge

BMC Public Health ◽

10.1186/s12889-021-10619-w ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Zahra Sharif ◽

Farzad Peiravian ◽

Jamshid Salamzadeh ◽

Nastaran Keshavarz Mohammadi ◽

Ammar Jalalimanesh

Keyword(s):

Health Systems ◽

Information Flow ◽

Complex Adaptive Systems ◽

Adaptive Systems ◽

Emergent Behavior ◽

System Level ◽

Antibiotics Resistance ◽

Policy Document ◽

Complex Adaptive ◽

Antibiotics Use

Abstract Background Irrational use of antibiotics is proving to be a major concern to the health systems globally. This results in antibiotics resistance and increases health care costs. In Iran, despite many years of research, appreciable efforts, and policymaking to avoid irrational use of antibiotics, yet indicators show suboptimal use of antibiotics, pointing to an urgent need for adopting alternative approaches to further understand the problem and to offer new solutions. Applying the Complex Adaptive Systems (CAS) theory, to explore and research health systems and their challenges has become popular. Therefore, this study aimed to better understand the complexity of the irrational use of antibiotics in Iran and to propose potential solutions. Method This research utilized a CAS observatory tool to qualitatively collect and analyse data. Twenty interviews and two Focus Group discussions were conducted. The data was enriched with policy document reviews to fully understand the system. MAXQDA software was used to organize and analyze the data. Result We could identify several diverse and heterogeneous, yet highly interdependent agents operating at different levels in the antibiotics use system in Iran. The network structure and its adaptive emergent behavior, information flow, governing rules, feedback and values of the system, and the way they interact were identified. The findings described antibiotics use as emergent behavior that is formed by an interplay of many factors and agents over time. According to this study, insufficient and ineffective interaction and information flow regarding antibiotics between agents are among key causes of irrational antibiotics use in Iran. Results showed that effective rules to minimize irrational use of antibiotics are missing or can be easily disobeyed. The gaps and weaknesses of the system which need redesigning or modification were recognized as well. Conclusion The study suggests re-engineering the system by implementing several system-level changes including establishing strong, timely, and effective interactions between identified stakeholders, which facilitate information flow and provision of on-time feedback, and create win-win rules in a participatory manner with stakeholders and the distributed control system.

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Analysing “the Workings” of Health Systems as Complex Adaptive Systems

Health System Redesign ◽

10.1007/978-3-319-64605-3_9 ◽

2017 ◽

pp. 165-191

Author(s):

Joachim P. Sturmberg

Keyword(s):

Health Systems ◽

Complex Adaptive Systems ◽

Adaptive Systems ◽

Complex Adaptive

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Irrational use of antibiotics in Iran from the Perspective of Complex Adaptive Systems: redefining the challenge

10.21203/rs.3.rs-56008/v2 ◽

2020 ◽

Author(s):

Zahra Sharif ◽

Farzad Peiravian ◽

Jamshid Salamzadeh ◽

Nastaran Keshavarz Mohammadi ◽

Ammar Jalalimanesh

Keyword(s):

Health Systems ◽

Information Flow ◽

Complex Adaptive Systems ◽

Adaptive Systems ◽

Emergent Behavior ◽

System Level ◽

Antibiotics Resistance ◽

Policy Document ◽

Complex Adaptive ◽

Antibiotics Use

Abstract Background: Irrational use of antibiotics is proving to be major concern to the health systems globally. It results in antibiotics resistance and increases health care costs. In Iran, many years of research, appreciable efforts and policy making have been of little avail and indicators still show suboptimal use of antibiotics, pointing to an urgent need for adopting an alternative approach to understanding the problem and generating new solutions. Applying the Complex Adaptive Systems theory, to explore and research in health systems and their challenges has become popular. Therefore, this study aimed to better understand the complexity of irrational use of antibiotics use in Iran and to propose potential solutions. Method: This research utilized a CAS observatory tool to qualitatively collect and analyse data. Twenty interviews and two Focus Group Discussion were conducted. The data was enriched with policy document reviews to fully understand the system. MAXQDA software was used to organize and analyze the data. Result: We could identify several diverse and heterogeneous, yet highly interdependent agents operating at different levels in the antibiotics use system in Iran. The network structure and its adaptive emergent behavior, information flow, governing rules, feedback and values of the system, and the way they interact were identified. The findings describe antibiotics use as an emergent behavior which is formed by an interplay of many factors and agents over time. Insufficient and ineffective interaction and information flow regarding antibiotics between agents were among key causes of irrational antibiotics use in Iran. Results showed that effective rules to minimize irrational use of antibiotics are missing or can be easily disobeyed. The gaps and weakness of the system which needs redesigning or modification were recognized as well. Conclusion: The study suggests re-engineering the system by implementing several system-level changes including establishing strong, timely, and effective interactions between identified stakeholders, which facilitate information flow and provision of on-time feedback, and create win-win rules in a participatory manner with stakeholders and the distributed control system.

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Irrational use of antibiotics in Iran from the Perspective of Complex Adaptive Systems: redefining the challenge

10.21203/rs.3.rs-56008/v1 ◽

2020 ◽

Author(s):

Zahra Sharif ◽

Farzad Peiravian ◽

Jamshid Salamzadeh ◽

Nastaran Keshavarz Mohammadi ◽

Ammar Jalalimanesh

Keyword(s):

Health Systems ◽

Information Flow ◽

Complex Adaptive Systems ◽

Adaptive Systems ◽

Antibiotic Use ◽

Analysis Data ◽

Antibiotic Consumption ◽

System Level ◽

Antibiotics Resistance ◽

Complex Adaptive

Abstract Background: Irrational use of antibiotics proves major concerns to the health systems globally. It results in antibiotics resistance and increases health care costs. In Iran, many years of research, appreciable efforts and policy making have been of little avail and indicators still show suboptimal use of antibiotics, pointing out an urgent need to alternative approach to understand the problem and generate new solutions. Applying the Complex Adaptive Systems theory, to explore and research in health systems and their challenges and has become popular. Therefore, this study was aimed to better understand the complexity of irrational use of antibiotic use in Iran and the potential solutions. Method: This research utilized a CAS observatory tool to qualitatively collect and analysis data. Many interviews with key informants were conducted. The data was enriched with documents reviews in order to fully understand the system. MAXQDA software was applied to organize and analyze the data. Result: We could identify several diverse and heterogeneous, yet highly interdependent agents in the antibiotic consumption system in Iran, operating at different levels. The network structure and its adaptive emergent behaviour, information flow, governing rules, feedbacks and values of the system and the way they interact were identified. The gaps and weakness of the system which needs redesigning or modification were recognized as well. Findings describe antibiotic use as an emerge behavior of the system which is formed by interplay of many factors and actors over time.Conclusion: The study suggests re-engineering the system by implementing several system level changes including establishing strong, timely and effective interactions between identified stakeholders which facilitate information flow and provision of on time feedbacks, create win-win rules in participatory manner with stakeholders and distributed control system.

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