The document provides an introduction to complex health systems through a series of concepts and frameworks: - It discusses shifting perspectives from health programs to health systems development and complex adaptive health systems. - Key concepts are introduced like the "Martian view" and "Gorilla view" of systems, as well as threshold concepts about the socially constructed and integrated nature of health systems. - It also covers complexity concepts like self-organization, feedback loops, and emergence. Frameworks for different forms of complexity and four revolutions transforming health systems are presented. - Systems thinking is discussed as giving insights into how systems work and can be improved, emphasizing relationships and processes over structures. Small changes can produce big results

1. ICHS 8
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Introduction to Complex Health
Systems
Introduction to
complex health
systems: wrap-up

2. Story of the week
from health programmes and services
to
health systems and
health systems development
to
complex adaptive health systems and
leading change within them

3. 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

4. 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.

5. Spot the complexity
concept
• Self-organising
• History dependent
• Feedback loops
• Emergence
• Sensemaking
• Tipping points
• Non-linear
• Interestingly, not
power (but is
important)

6. 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

7. 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

8. 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.

9. 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).

10. 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...

11. Leverage points when intervening in a system
(in increasing order of effectiveness)
9. Constants, parameters, numbers, subsidies
8. Regulating negative feedback loops
7. Driving positive feedback loops
6. Material flows
5. Information flows
4. Rules of the system (incentives, constraints)
3. Distribution of power over the rules of the system
2. Goals of the system
1. The mindset or paradigm out of which the system
– its goals, power structure, rules, culture arises.
Modified from Donella Meadows

12. 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

13. 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

14. 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

15. System thinking skills
Usual approach Systems thinking approach
Static thinking Dynamic thinking
focus on events focus on patterns of behaviour

16. System thinking skills
Usual 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

17. System thinking skills
Usual 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

18. System thinking skills
Usual 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

19. System thinking skills
Usual 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

20. Systems thinking
Solving 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.

22. The CHEPSAA partners
University of Dar Es Salaam
Institute of Development Studies
University of the Witwatersrand
Centre for Health Policy
University of Ghana
School of Public Health, Department of
Health Policy, Planning and Management
University of Leeds
Nuffield 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 Medicine
Health Economics and Systems Analysis
Group, Depart of Global Health & Dev.
Great Lakes University of Kisumu
Tropical Institute of Community Health and
Development
Karolinska Institutet
Health Systems and Policy Group,
Department of Public Health Sciences
University of Cape Town
Health Policy and Systems Programme,
Health Economics Unit
Swiss Tropical and Public Health
Institute
Health Systems Research Group
University of the Western Cape
School of Public Health