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Blog

The conversion of a complex adaptive systems modeling sceptic

Future Health Systems

During the past few years complex adaptive systems theory has suddenly become very popular in the health systems research field. However, I have to admit that, until recently, I was something of a complex systems modeling sceptic. A couple of recent events, notably the FHS workshop and an NIH conference, have changed my perspective. Here's what has driven my change in thinking.

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Communicating complexity

Future Health Systems

Alexander Galloway (2011) in his article ‘Are some things unrepresentable?’ cites a causal loop diagram as an example of a critical tension in communication where the more information that is represented the less information is actually conveyed. He dubs it ‘McChrystal’s Law’, and then proceeds to suggest that such visualisations contribute to a political violence committed against the viewer, in part because the aesthetics of the diagram overstate its ability to represent. Yikes!

Unfortunately, McChrystal’s Law is just the tip of the iceberg when it comes to communicating complexity. At a three-day workshop jointly convened by Future Health Systems and the STEPS Centre examining complex adaptive systems (CAS), we had an interesting discussion about some of those challenges.

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Complexity in practice: Experiences from research to improve maternal health in Uganda

Future Health Systems

Many will already be familiar with the term ‘complex adaptive systems’ (CAS). It’s certainly something we’ve talked about a lot within the Future Health Systems consortium. But it’s a term, and concept and a practice that has taken me some time to fully comprehend and to utilize in my own work. We are implementing a number of implementation research projects in Eastern Uganda, and most of my attention has been focused on the day-to-day operations of these large projects. However, I’ve found CAS tools to help me step back and get a broader picture of our research intervention. Here’s why.

 

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How participatory is participatory modelling for complex adaptive systems?

Future Health Systems

At a recent workshop on methods for understanding complex adaptive systems (CAS) in the context of health systems strengthening, we looked at a number of modelling techniques, like agent-based modeling and causal loop diagrams, some purporting to be participatory in nature. But is the idea of participatory approaches to complex systems thinking inherently contradictory? Inherently confusing? Or are they revolutionary, altering how we see the world and empowering us to transform health systems radically?

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Capturing the legacy of and learning from long-term programmes using innovation histories

Future Health Systems

At the recent workshop on methods for complex adaptive systems (CAS) research in Baltimore, jointly organised by the STEPS Centre and Future Health Systems, thoughts turned to the legacy of such long-term programmes. Though they had different funders, both STEPS and FHS started in 2006. So now, as both programmes start thinking about their 10th anniversaries, how can we begin to summarise all that research and the influence that it has had?

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Ten things to know about causal loop diagrams (CLDs)

Future Health Systems

As discussed at a methods workshop held in Baltimore in June 2014, systems mapping and conceptualization – a key part of the puzzle of intervening in complex systems – is a process of developing diagrams to illustrate system boundaries and the connections between variables.

CLDs are one type of system map, but they are by no means the only one. What makes CLDs particularly useful is that, in addition to mapping a system structure, they help build understanding of connections between a range of variables.

The increased momentum around complexity and tools such as the CLDs begin to raise issues that question the very core of the paradigms in which we generally operate in public health. That creates demand for understanding what CLDs are and when to develop and use them. It also creates an opportunity to drop some of the communication barriers that exist between disciplines and to push the boundaries of our understanding of complex systems.

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New methods needed: How can complexity science help us to understand pluralistic health systems?

Future Health Systems

Until recently, the dominant view of a health system was as a combination of building blocks -- such as human resources, finance and so forth -- capable of delivering a package of services. The construction of this kind of health system was seen as relatively straight forward.

However, a number of studies have challenged this view by demonstrating the important influence of context on health system performance. This has stimulated an interest among health system analysts in the application of concepts associated with complex adaptive systems to the challenge of managing health system development and change.

This was the theme of a workshop jointly organised by Future Health Systems and the STEPS Centre in Baltimore in June 2014. The workshop provided an opportunity for an exchange of ideas between people whose focus has been on the analysis of health systems, those involved in systems thinking and the role of modelling and those who bring a social science perspective to the analysis of complex and dynamic contexts.

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7 Things Everyone Should Know About DFID’s Approach To Health Systems Strengthening

Future Health Systems

At the end of June, the UK Parliament’s International Development Committee heard oral evidence about the UK Department for International Development’s (DFID’s) efforts to improve health systems in low- and middle-income countries (LMICs). But why do health systems matter? And what is health systems strengthening anyway? Here are the top things you need to know. Click through to original post on Buzzfeed.

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Is the health system response out of sync with the demands of the islanders in the Indian Sundarbans?

Future Health Systems

Five years ago, a mid-summer nightmare named Aila crashed on the Sundarbans with murderous fury and wreaked destruction beyond repair. On May 25, 2009 the tropical cyclone hit the Sundarbans in India and Bangladesh with a wind speed of 110 km/hr. Over 8,000 people went missing and more than a million were rendered homeless in the two countries. In India about 300 people were killed in Sagar Island alone in the Indian Sundarbans. Figures can scarcely do justice to record the number of homes destroyed, lives lost and livelihoods decimated.

There was a localised health system collapse in the immediate aftermath of Aila – a fact attested by the islanders loudly and by the state health policy makers privately.

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From ‘Basket Case’ to ‘One of the Great Mysteries of Global Health’: How did Bangladesh become such a success story?

Future Health Systems

Last week I was lucky enough to attend the UK launch of the Lancet Special Issue on Bangladesh, Innovation for Universal Health Coverage. In addition to this blog, there is also a complete Storify of the event.

Bangladesh is a fascinating case study for this type of review because, in terms of many health and social status indicators, they outperform many of their neighbouring countries despite having a lower GDP. This is particularly surprising as their health system is weak in many respects and is pluralistic, characterised by a range of health service providers from the for-profit and not-for-profit private sectors. Per capita expenditure on health care is $27 and two thirds of payments for health care are out of pocket – meaning that government investment in the health sector is very low. There are only 0.3 doctors/nurses per 1000 population. Despite this Bangladesh is one of six countries which is on-track to achieve Millennium Development Goals 4 and 5 on child and maternal health.

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Storify of FHS event - Why development matters for health systems: Lessons from Bangladesh

Future Health Systems

Last Friday, FHS co-hosted an event with the Institute of Development Studies and the Brighton and Sussex Medical School to help launch a recent special series from The Lancet on Bangladesh. We were pleased to welcome both FHS Research Co-Director Abbas Bhuiya, Deputy Director of icddr,b, and Mushtaque Chowdhury, Vice Chair and Interim Executive Director of BRAC.

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The 4Cs of the Health Systems in Asia Conference

Future Health Systems

During the Health Systems in Asia conference last weekend in Singapore, I was able to identify a clear trend. No, not pluralism in Asian health systems, we already knew that one. But rather, on two of the four days the closing thoughts from different speakers involved 4Cs. In keeping with this important new trend, I’ve decided to frame my blog similarly. And so I present to you my four takeaways from the conference using the same ‘4C framework’: Confucius, context, communication, and coverage.

 

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    Two hops from FHS: What can our Facebook page tell us about our network?

    Future Health Systems

    The other week I had the good fortune of participating in an excellent meeting in Prague hosted by the Open Society Foundations: Policy Research, Technology and Advocacy Event @ the Hub. The event was designed to bring experts together from across Central and Eastern European think tanks to share ideas and learn from each other on innovative approaches to evidence-based advocacy and communications.

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    The ethics of emergent knowledge intermediaries

    Future Health Systems

    The use of new knowledge intermediaries in the public health sphere gives rise to a host of ethical issues. These include questions about fairness of access; the quality of the technology used and information generated; who has access to and control of such information; the impact of commercial interests within a healthcare setting; and regulation across borders. How do we address all of these from within our current frameworks of ethical thinking in medicine? In fact, can we?

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    Innovations on the ground: Implications for ICTs in patient self-management

    Future Health Systems

    This series of interviews with participants in a recent workshop on patient self-management hosted by IDS at the Brocher Foundation explores how information and communication technologies are being used to help people cope with chronic diseases in Cambodia, Bangladesh and Uganda. From Cambodia, we hear from Maurits van Pelt of MoPoTsyo, a patient peer group for diabetes sufferers in Cambodia. Dr Mohammed Iqbal from icddr,b talks about chronic disease clubs in Chakaria, Bangladesh. And William Roy Mayega discusses advances in Uganda on treating chronic diseases.

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    The ethical implications of new diagnostic technologies: how personal should we get?

    Future Health Systems

    Diagnostic categories will always be a site of contestation, often linked as much to contemporary standards of morality and normality as to medicine’s capacity to detect disease. But with the global diagnostic industry expanding to be worth $49.2 billion in 2012, and with emerging NCD markets in the BRIC countries behind much of that growth, it is timely to ask if there are developments in diagnostics that are bringing new social, moral or legal concerns to the fore. And how might these play out in the emerging markets?

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    New technologies: Causing and solving the healthcare funding crisis?

    Future Health Systems

    While health economists and actuaries may devise sophisticated models to estimate the costs and benefits of healthcare, it is not only the rich, but the majority of individuals who will insist that no price is too high to pay to delay death or reduce the disability or suffering of themselves or loved ones. However, while the rich can take care of themselves, the rest of us rely on collective risk-sharing arrangements, through various forms of insurance or social welfare schemes. Unfortunately, as advances in medical technology provide new possibilities for extending life by managing serious illness – at an ever increasing cost – the sustainability of such schemes is often called into question.

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