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

Eric Sarriot,Michelle Kouletio

doi:10.1007/s11213-014-9329-9

Eric Sarriot, Michelle Kouletio

Open Access

https://doi.org/10.1007/s11213-014-9329-9

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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.

Highlights

Syst Pract Action Res (2015) 28:255–272Much development and humanitarian thinking and practice is still trapped in a paradigm of predictable, linear causality and maintained by mindsets that seek accountability through top-down command and control
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
We focus on understanding the health systems as complex adaptive systems and draw lessons from the experience of the project with the two municipal systems

Summary

Introduction

Syst Pract Action Res (2015) 28:255–272Much development and humanitarian thinking and practice is still trapped in a paradigm of predictable, linear causality and maintained by mindsets that seek accountability through top-down command and control. Recent years have seen more emphasis on the mechanistic approaches of this paradigm and the kinds of procedures which are increasingly questioned by successful private sector organizations This has widened the gap between actual aid practices and the rhetoric of the many initiatives which aim to improve them—including aid effectiveness, institutional reform, participation, local ownership and empowerment. This interest is born from (1) the realization that health and development programs are confronted with complex and disorderly patterns (Paina and Peters 2011; Gasparatos et al 2007; Sarriot et al 2004), (2) repeated failures in attempting to sustain achievements due to vexing problems (Hafner and Shiffman 2013; Lafond 1995), and (3) increasing attempts of global health interventions to deliver discrete results and strengthen entire systems of care, build capacity, as well as achieve ownership and sustainability (Baser and Morgan 2008; Brinkerhoff and Morgan 2010; de Savigny and Adam 2009; Gruen Gruen 2008; Paina and Peters 2011; Ubels et al 2010)

Objectives

Conclusion