Systems Thinking for Systems Building

Ronald Heifetz in his 1998 book Leadership Without Easy Answers first brought to us the concept of doing adaptive work when tackling complex issues. Providing systems of care for children with behavioral health issues, integrating primary care and behavioral health, taking a public health approach to children’s mental health, addressing disparities, providing family driven and youth guided services and integrating cultural and linguistic competence are but a few changes that health systems in the US have undertaken during these last three decades.

When trying to intervene in any such complex system, it is increasingly clear that the nature of the work is neither primarily technical nor adaptive. Effective systems require technical interventions that require responding to expected and anticipated fairly simple or even complicated challenges. On the other hand when the issues at hand are complex and the solutions are not necessarily at hand and it requires a collaborative approach then clearly adaptive work is needed.

According to Plesk P.E. and Greenhaigh, T. in their article The Challenge of Complexity in Health Care address the following aspects:

  1. Complex systems have the capacity to be adaptable and can learn and change themselves.
  2. Systems are embedded within other systems and this is critical to remember because one part of the system influences another part. This can have both positive and negative consequences, e.g. changing clinic hours to accommodate working families can disrupt the family time of health care providers.
  3. Health systems are both orderly and unpredictable at times and individuals within these systems will need to learn to deal with both, and
  4. Contradictions and conflict are inherent within these systems and need on-going attention and should be seen as opportunities for forward movement on issues and not necessarily requiring immediate resolution.

What are the practical implications of viewing health systems as complex adaptive rather than mechanical systems? A question posed by The World Bank in a 2007 article entitled: What is a Health System? According to them it means the following:

Understand the context, look for connections between the parts (e.g., between programs, between demand and supply, across sectors), anticipating downstream consequences and identifying upstream points of leverage.
Focus on simple rules to produce complex outcomes. Balance three types of rules that: (1) set direction (e.g., leadership and vision); (2) set prohibitions (e.g., regulations and boundary setting); (3) provide permission (e.g., setting incentives or providing resources).
Understand how organizational structure influences behavior, and lastly
Use data to guide decisions. Constantly looking at how health systems perform is the best way to see how it is actually behaving and whether a project or new intervention is making a difference.

Heifetz, R. Leadership Without Easy Answers. Harvard University Press, 1994.
Plesk P.E. and Greenhaigh, T. The Challenge of Complexity in Health Care 2001
Healthy Development The World Bank Strategy for HNP Results Annex L–April 24, 2007