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Complex adaptive systems

Recognising that health interventions take place in complex adaptive systems, we are undertaking systematic learning processes that bring together key actors involved in service delivery and working to understand how iterative, evidence-informed approaches to health systems change can improve implementation.

Recent FHS publications on 'complex adaptive systems'


Xiao, Y, Husain, L and Bloom, G (2018) Evaluation and learning in complex, rapidly changing health systems, Globalization and Health, 14:112, DOI: 10.1186/s12992-018-0429-7

Healthcare systems are increasingly recognised as complex, in which a range of non-linear and emergent behaviours occur. China’s healthcare system is no exception. The hugeness of China, and the variation in conditions in different jurisdictions present very substantial challenges to reformers, and militate against adopting one-size-fits-all policy solutions. As a consequence, approaches to change management in China have frequently emphasised the importance of sub-national experimentation, innovation, and learning. Multiple mechanisms exist within the government structure to allow and encourage flexible implementation of policies, and tailoring of reforms to context. These limit the risk of large-scale policy failures and play a role in exploring new reform directions and potentially systemically-useful practices. They have helped in managing the huge transition that China has undergone from the 1970s onwards. China has historically made use of a number of mechanisms to encourage learning from innovative and emergent policy practices. Policy evaluation is increasingly becoming a tool used to probe emergent practices and inform iterative policy making/refining. This paper examines the case of a central policy research institute whose mandate includes evaluating reforms and providing feedback to the health ministry. Evaluation approaches being used are evolving as Chinese research agencies become increasingly professionalised, and in response to the increasing complexity of reforms. The paper argues that learning from widespread innovation and experimentation is challenging, but necessary for stewardship of large, and rapidly-changing systems.

Husain L (2017) Policy experimentation and innovation as a response to complexity in China’s management of health reforms, Globalization and Health, 13:54, doi: 10.1186/s12992-017-0277-x

There are increasing criticisms of dominant models for scaling up health systems in developing countries and a recognition that approaches are needed that better take into account the complexity of health interventions. Since Reform and Opening in the late 1970s, Chinese government has managed complex, rapid and intersecting reforms across many policy areas. As with reforms in other policy areas, reform of the health system has been through a process of trial and error. There is increasing understanding of the importance of policy experimentation and innovation in many of China’s reforms; this article argues that these processes have been important in rebuilding China’s health system. 

Buckland Merrett GL, Bloom G, Wilkinson A and MacGregor H (2016) Towards the just and sustainable use of antibiotics, Journal of Pharmaceutical Policy and Practice, 9:31, DOI: 10.1186/s40545-016-0083-5

The emergence and spread of antibiotic resistant pathogens poses a big challenge to policy-makers, who need to oversee the transformation of health systems that evolved to provide easy access to these drugs into ones that encourage appropriate use of antimicrobials, whilst reducing the risk of resistance. This is a particular challenge for low and middle-income countries with pluralistic health systems where antibiotics are available in a number of different markets. This review paper considers access and use of antibiotics in these countries from a complex adaptive system perspective. It highlights the main areas of intervention that could provide the key to addressing the sustainable long term use and availability of antibiotics.

Wang L, Zhang X, Liang X and Bloom G (2016) Addressing antimicrobial resistance in China: policy implementation in a complex context, Globalization and Health, 12:30, DOI: 10.1186/s12992-016-0167-7

The effectiveness of antibiotics in treating bacterial infections is decreasing in China because of the widespread development of resistant organisms. Although China has enacted a number of regulations to address this problem, but the impact is very limited. This paper investigates the implementation of these regulations through the lens of complex adaptive systems (CAS).

Complex and dynamic public health problems require a different approach: an emphasis on the value of people. People who own the problem can anticipate the most likely social obstacles to its resolution, and their participation is essential to maintain an evolving strategy that can institutionalize an approach to the problem.

This paper explores the question of what systems thinking adds to the field of global health. Observing that elements of systems thinking are already common in public health research, the article discusses which of the large body of theories, methods, and tools associated with systems thinking are more useful. 

This paper explores the evolution of schemes for rural finance in China as a case study of the long and complex process of health system development. It argues that the evolution of these schemes has been the outcome of the response of a large number of agents to a rapidly changing context and of efforts by the government to influence this adaptation process and achieve public health goals.

This presentation is from a workshop in Baltimore in June 2014 on complex adaptive systems (CAS) research methods held at Johns Hopkins University. In this presentation, Ligia Paina from the Johns Hopkins Bloomberg School of Public Health shows how to use the computer program Vensim to develop Causal Loop Diagrams (CLDs).