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

Abstract

The global health and development field, which has been reasonably dominated by linear models of planning, is witnessing increased interest in complexity, non-linear processes, and systems thinking. This welcome interest is challenged by both language and ability to discern whether complex development phenomena are discussed from the perspective of the nature of particular health systems (ontology), from the identification of more fitting intervention modalities (praxis), or from our approach to learning and evidence (epistemology). This paper is an experience-based contribution to the first two perspectives. Two Bangladeshi municipal health systems provide an example of how sustainable outcomes were achieved through complex adaptive system behaviors, during and after intervention by Concern Worldwide, Inc. (Concern). Concern provided support to the Municipal Health Departments and then assessed the sustainability of health achievements several years after its intervention. We examine complexity in municipal health systems behavior, and the nonlinearity of project effects. We identify ways in which Concern's program, beyond technical design, followed recommendations on leading complex systems towards positive sustainable outcomes. We conclude on the necessity for global community health planners and practitioners to (1) better understand the complexity of the context and issues they are facing, (2) make more reasonable assumptions about the ''shock to the system'' caused by projects both when they start and when they end, and (3) learn to balance strategic designs with respect for self-organization principles.

Self-Organization and Emergence in Global Health. Insights From Practice, Blind Spots and Possible Contributions From Complexity Science

“…An assessment five-year post-project [25] describes elements of self-organization among stakeholders of an urban health project in Bangladesh. While on the surface the architecture for urban community health was as-expected, different groups' self-interest led to a working equilibrium between all parties [26].…”

Knowledge as enablement: additional perspectives influenced by complexity

“…The interactions between the variables produce linear, cause-effect outcomes that are predictable (Sarriot & Kouletio, 2014). These variables are discrete, but they are dominating factors that influence the identity and characteristics of a closed system.…”

Service quality and maturity of health care organizations through the lens of Complexity Leadership Theory

“…Sturmberg et al suggested a complex health care system model for understanding health system reform. Sarriot and Kouletio found that health systems, through complex adaptive behaviours, achieved sustainable outcomes. They found that some of the quality indicators of service were improved significantly after adopting complexity in a number of hospitals.…”

“…To cope with the growing complexity in health care organizations and to ensure or improve the quality of health outcomes, linear models should be abandoned . Rather, there is a growing interest in the application of complex, nonlinear models to health systems . Nonlinearity designates that repetition of the same issue can lead to different outcomes .…”

“…Nonlinearity designates that repetition of the same issue can lead to different outcomes . Many authors in their research view health care organizations as CAS . Sturmberg et al suggested a complex health care system model for understanding health system reform.…”