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.
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In public health research, the focus has traditionally been on descriptive and analytic epidemiological research (“what”, “why”, “where,” and “who”). Less attention has been given, particularly in low-income countries, to “how” interventions do or do not work in the “real world”, given the involvement of different actors, the context in which implementation occurs, and the factors that influence implementation. Future Health Systems (FHS) has been at the forefront in the exploration, application and growth of implementation research (IR).
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.
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Systems thinking represents a unique theoretical and practical contribution. It facilitates ways to cross disciplines, and brings previously unused tools and approaches to tackle global health implementation differently. Future Health Systems (FHS) has played a major role in applying and advocating for the approach as a means to holistically understand health systems in low- and middle-income countries, as well as adaptation and scale-up of the project’s interventions.
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.
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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).
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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.
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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.
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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.
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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).
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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, Agnes Rwashana Semwanga gives an overview of two case studies where the Causal Loop Diagram methodology has been applied to health systems research.
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This presentation kicked off a workshop in Baltimore in June 2014 on complex adaptive systems (CAS) research methods held at Johns Hopkins University. In the presentation, Ben Ramalingam, author of Aid on the Edge of Chaos, and Taghreed Adam from the Alliance for Health Policy and Systems research introduce concepts of CAS and situate the methods in the context of understanding health systems strengthening.
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In this presentation, Jeff Knezovich, FHS Policy Influence and Research Uptake Manager, discusses some of the challenges associated with communicating complexity research. He then suggests some techniques and tools to get around these challenges
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This is a video from the DC Health Systems Board event, Can systems tools deliver for the 'science of delivery'?, which was organised by Future Health Systems as part of its workshop on complex adaptive systems and held at Results for Development in June 2014.
At the event, panellists discussed and debated how systems thinking tools that are designed to tackle issues of complexity can contribute the successful implementation of health system strengthening interventions. The panel showcased some tools and examples, explaining how they had helped them to understand better health systems fluctuations and to anticipate unintended consequences to create more sustainable large-scale interventions.
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Health policy and systems research (HPSR) is a transdisciplinary field of global importance, with its own emerging standards for creating, evaluating, and utilizing knowledge, and distinguished by a particular orientation towards influencing policy and wider action to strengthen health systems. In this commentary, we argue that the ability of the HPSR field to influence real world change hinges on its becoming more people-centred. We see people-centredness as recognizing the field of enquiry as one of social construction, requiring those conducting HPSR to locate their own position in the system, and conduct and publish research in a manner that foregrounds human agency attributes and values, and is acutely attentive to policy context.
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Many Asian countries are in the midst of multiple interconnected social, economic, demographic, technological, institutional and environmental transitions. These changes are having important impacts on health and well-being and on the capacity of health systems to respond to health-related problems. This paper focuses on the creation of institutions to overcome information asymmetry and encourage the provision of safe, effective and affordable health services in this context of complexity and rapid change.
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In 2009 the government of China identified an essential drugs policy as one of five priority areas for health system reform. Since then, a national essential drugs policy has been defined, along with plans to implement it. As a large scale social intervention, the policy will have a significant impact on various local health actors. This paper uses the lens of complex adaptive systems to examine how the policy has been implemented in three rural Chinese counties. Using material gathered from interviews with key actors in county health bureaus and township health centers, we illustrate how a single policy can lead to multiple unanticipated outcomes. The complexity lens applied to the material gathered in interviews helps to identify relevant actors, their different relationships and policy responses and a new framework to better understand heterogeneous pathways and outcomes. Decision-makers and policy implementers are advised to embrace the complex and dynamic realities of policy implementation. This involves developing mechanisms to monitor different behaviors of key actors as well as the intended outcomes and unintended consequences of the policy.
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Although health interventions start with good intentions to develop services for disadvantaged populations, they often distort the health market, making the delivery or financing of services difficult once the intervention is over: a condition called the ‘Develop-Distort Dilemma’ (DDD). In this paper, we describe how to examine whether a proposed intervention may develop or distort the health market. Our goal is to produce a tool that facilitates meaningful and systematic dialogue for practitioners and researchers to ensure that well-intentioned health interventions lead to productive health systems while reducing the undesirable distortions of such efforts.
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In recent years, there have been several calls for rigorous health policy and systems research to inform efforts to strengthen health systems (HS) in low- and middle-income countries (LMICs), including the use of systems thinking concepts in designing and evaluating HS strengthening interventions. The objectives of this paper are to assess recentevaluations of HS strengthening interventions to examine the extent to which they ask a broader set of questions, and provide an appropriately comprehensive assessment of the effects of these interventions across the health system.
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Dr David Bishai gives an introduction complex adaptive systems and their application to health systems modelling and strengthening.
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