System Perspective Research Articles

Cost-utility of sirolimus in the treatment of vascular malformations.

Sirolimus is being increasingly employed to manage specific vascular anomalies. We performed an exploratory cost-utility analysis to evaluate sirolimus as a treatment for vascular malformations from the Australian healthcare system perspective. Over a one-year time horizon, sirolimus treatment was associated with an increased expenditure of AU$2832.80 and a gain of 0.08 quality-adjusted life years (QALYs) when compared to supportive care, resulting in an incremental cost-effectiveness ratio of AU$35,410/QALY. By most metrics, sirolimus would be considered a cost-effective treatment for vascular malformations.

Animal-free safety assessment of chemicals: an innovation system perspective.

This perspective paper, which is the result of a collaborative effort between toxicologists and scholars in innovation and transition studies, presents a heuristic framework based on innovation system literature for understanding and appraising mission achievement to animal-free chemical safety assessment using New Approach Methodologies (NAMs). While scientific and technical challenges in this area are relatively well known, the recent establishment of missions and roadmaps to accelerate the acceptance and effective use of NAMs for chemical safety assessment raises new questions about how we can grasp the systemic nature of all changes needed in this transition. This includes recognising broader societal, institutional, and regulatory shifts necessary for NAM acceptance and uptake. Our paper discusses how the innovation system approach offers insights into key processes and associated activities that include as well as transcend the technical and scientific realm, and can help to accelerate acceptance and uptake of NAMs. Based on these insights, we present a comprehensive framework that, next to scientific and technological developments, recognises the need for coordinated efforts in areas like education, training, funding, policy-making, and public engagement to promote the acceptance and uptake of NAMs. Our framework can be used to perform structural and functional analyses of the innovation system of NAMs and animal-free safety assessment and as such provides handholds to track progress and organise collective efforts of actors to make sure we are moving in the right direction.

Cost-Effectiveness of Bivalent Respiratory Syncytial Virus PrefusionF (RSVpreF) Vaccine During Pregnancy for Prevention of Respiratory Syncytial Virus Among Infants in Argentina.

Lower respiratory tract illness (LRTI) caused by respiratory syncytial virus (RSV) is common among young children in Argentina. Use of the currently available prophylactic agent is limited to children aged ≤ 2years with selected high-risk conditions, and thus the majority of infants remain unprotected. We estimated the value-based price (VBP) of a novel RSVpreF vaccine for use among pregnant people for prevention of RSV-LRTI among infants during the first year of life. Clinical outcomes and economic costs of RSV-LRTI during infancy and expected impact of RSVpreF vaccination during pregnancy were projected using a population-based Markov-type cohort model. Model results-estimated on the basis of gestational age at birth, disease/fatality rates, and mother's vaccination status-include total numbers of RSV-LRTI cases, RSV-LRTI-related deaths, and associated costs. Base case analyses (RSVpreF vs. no vaccine) were conducted from the healthcare system perspective. Probabilistic sensitivity analyses (PSA; 1000 replications) were also conducted. Willingness-to-pay (WTP) was $10,636 per quality-adjusted life-year (QALY; i.e., 1 × 2021 gross domestic product [GDP] per capita) in base case analyses and PSA. Costs are reported in USD, estimated on the basis of the June 22, 2023 exchange rate. Use of RSVpreF among 342,110 pregnant persons provided protection to 330,079 infants at birth. In total, RSVpreF prevented 3915 RSV hospitalizations, 6399 RSV cases requiring emergency department care, 6182 RSV cases requiring a physician office visit, and 67 disease-related deaths. Direct costs were projected to be reduced by $5.0million. With 2061 QALYs gained and vaccine administration cost of $1.4million, the VBP of RSVpreF was estimated to be $74.46 per dose. In PSA, mean VBP was $75.02 (95% confidence interval 54.24-97.30). RSVpreF among pregnant persons would significantly reduce the clinical and economic burden of RSV-LRTI among infants in Argentina and would be considered a cost-effective intervention up to a price of approximately $75.

A generic shared attention mechanism for various backbone neural networks

The self-attention mechanism is crucial for enhancing various backbone neural networks’ performance. However, current methods add self-attention modules (SAMs) to each network layer without fully utilizing their potential, resulting in suboptimal performance and higher parameter consumption as network depth increases. In this paper, we reveal an inherent phenomenon: SAMs produce highly correlated attention maps across layers, with an average Pearson correlation coefficient of 0.85. Inspired by this inherent observation, we propose Dense-and-Implicit Attention (DIA), which shares SAMs across layers and uses a long short-term memory module to calibrate and connect these correlated attention maps, improving parameter efficiency. This approach aligns with the neural network’s dynamic system perspective. Extensive experiments show DIA consistently enhances various backbones like ResNet, Transformer, and UNet in tasks such as image classification, object detection, and image generation with diffusion models. Our analysis indicates that DIA’s effectiveness stems from its dense inter-layer information connections, absent in conventional mechanisms, stabilizing training and providing regularization effects. This paper’s insights advance our understanding of attention mechanisms, optimizing them and paving the way for future developments across diverse neural networks.

Assessment on resilience of urban agglomeration transportation system considering passenger choice and load-capacity factor

Intercity transportation system (ICTS), characterized by large-scale, high spatial-temporal concentration, and sparser departure frequencies, is more vulnerable in unexpected events. Understanding the resilience characteristics of ICTS is crucial for maintaining the network service capabilities. Aiming to conduct effective resilience assessment on ICTS, we develop the resilience simulation model by introduce dual-regulated parameters for network load and capacity into cascading propagation model under interruption events, and quantify the impact of travel distance, time costs, and route redundancy on travel choice of passengers. Meanwhile, propose service resilience indicators from both the passenger's and the system's perspectives. Finally, we conduct a case study on the resilience of ICTS in Beijing-Tianjin-Hebei Urban Agglomerations (BTH-UA). The results show that: 1) Multimodal transportation systems usually exhibit better resilience than unimodal systems. 2) For various resilience optimization metrics, it is essential to choose targeted recovery strategies to maximize network resilience. 3) Traveler sensitivity to travel time significantly influences the resilience of passenger-based network services. 4) Changes in transportation supply capacity and travel demand will impact the system's resilience. The research findings can provide valuable references for the resilience development and management of urban transportation systems.

Cost-effectiveness of first-line sintilimab plus chemotherapy versus chemotherapy for advanced esophageal carcinoma in China

ABSTRACT Background To evaluate the cost-effectiveness of first-line sintilimab plus chemotherapy versus chemotherapy for advanced esophageal squamous cell carcinoma (ESCC) from the perspective of the Chinese health service system. Methods A partitioned survival model was constructed to simulate quality-adjusted life years and incremental cost-effectiveness ratios over a patient’s lifetime based on a phase III clinical trial. Results Sintilimab plus chemotherapy increased by 0.316 QALY and 0.285 QALY with the additional cost of $5692 and $5269, which led to the ICER of $18000/QALY and $18519/QALY gained in the overall population and the patients with CPS ≥ 10, respectively. Conclusions Compared with chemotherapy alone, sintilimab may be a cost-effective first-line treatment choice for locally advanced or metastatic ESCC.

Cost effectiveness of esophageal varices screening strategies of cirrhotic patients with portal hypertension

ObjectivesIn France, screening for esophageal varices (EVs) in cirrhotic patients with portal hypertension (PH) is performed by esophagogastroduodenoscopy (EGD). Though proven effective, EGD screening may be unpleasant for some patients. Our study sought to compare the cost-effectiveness of PillCam (Medtronic, Minneapolis, USA) esophageal capsule endoscopy (ECE), a less invasive test, versus EGD, for EV screening, from the perspective of the French national health system (NHS). In secondary objectives we compared the cost-effectiveness of ECE versus no screening for patients not compliant with EGD screening, and the cost-effectiveness of a screening strategy (ECE or EGD) versus no screening strategy at all. MethodsWe constructed a Markov model with data from the literature, applying it to two simulated cohorts of adult patients with cirrhosis and PH not previously screened for EVs. These patients were divided into EGD and ECE screening arms and tracked over a virtual 10-year period. Cost-effectiveness was defined as cost (in euros) per quality-adjusted life year (QALY). ResultsIn the base-case analysis, ECE is more expensive than EGD (€3,606 vs. €3,030) and less effective by 0.0098 QALY (5.2099 vs. 5.2197 QALYs). Probabilistic sensitivity analysis shows that ECE has only a 2.1% probability of being cost-effective at willingness-to-pay (WTP) of €30,000/QALY. ConclusionsAlthough patient compliance is apparently higher with ECE, it is not cost-effective at a WTP of €30,000/QALY and should not be considered in all patients with PH. Its cost-effectiveness should be reevaluated in the event of patient refusal of EGD follow-up. Public Interest SummaryEsophagogastroduodenoscopy (EGD) is gold standard to screen cirrhotic patients with portal hypertension for esophageal varices, but its unpleasantness lowers compliance. We evaluated the cost-effectiveness of a more acceptable alternative for patients: the esophageal capsule endoscopy (ECE).Our results show that screening by ECE is more expensive and less effective than by EGD from the perspective of the French national health system. It cannot be used as an alternative for all patients suffering from PH in France. Further investigations could be conducted to assess the effectiveness of ECE for the sub population of patients with PH who are totally refractory to EGD and may suffer from inadequate follow-up due to lack of screening.

National health and economic impact of a lifestyle program to prevent type 2 diabetes mellitus in Germany: a simulation study

IntroductionTo examine the long-term health and economic impact of a lifestyle diabetes prevention program in people with high risk of developing type 2 diabetes in Germany.Research design and methodsWe assessed...

A Study on the Path of Discipline Groups in Minzu Universities from the Balance and System Perspective

A Study on the Path of Discipline Groups in Minzu Universities from the Balance and System Perspective

Efficacy, Safety, and Economic Feasibility of Dokhwalgisaeng-Tang for Degenerative Knee Osteoarthritis: Protocol for a Multicenter, Randomized, Assessor Blinded, Controlled Trial.

Knee osteoarthritis (KOA) is one of the most prevalent degenerative joint diseases worldwide. The herbal decoction, Dokhwalgisaeng-tang (DHGST), has been commonly used in East Asia to treat osteoarthritis. However, there is insufficient evidence to draw clear conclusions concerning its effectiveness and safety for patients with KOA. We aim to determine the efficacy, safety, and economic feasibility of DHGST compared with Celecoxib, an oral COX-2 inhibitor, for patients with degenerative KOA. This multicenter, randomized, noninferiority trial, involving 160 participants who will be randomized using block randomization with 1:1 allocation, will compare DHGST and Celecoxib. The total trial period is 24weeks after random allocation, comprising 12weeks of treatment and 12weeks of follow-up. Participants with KOA will be administered 200 mg of DHGST (treatment group) or Celecoxib capsules (control group) for 12weeks. Efficacy and safety evaluations will be conducted at weeks 0, 4, 8, and 12, and 24. The primary outcome measurement is the Korean Western Ontario McMaster score at week 12. Changes in pain intensity using a 100 mm visual analog scale, changes in quality of life using a EuroQol 5-dimension 5-level self-report survey, and patient satisfaction will also be measured to evaluate effectiveness between the two groups. A trial-based economic feasibility evaluation will be conducted to analyze treatment cost-effectiveness from societal and healthcare system perspectives. Drug safety will be assessed through adverse reactions and laboratory test findings. This trial protocol has the following limitations. Applying a double-dummy design is not possible, as the tablet and granule forms can easily be distinguished visually, and achieving participant blinding is challenging. The trial findings are intended to inform participants, physicians, and other stakeholders in determining whether DHGST could be used as an alternative therapeutic option for KOA. KCT0008424 (Clinical Research Information Service of the Republic of Korea), registered on 12 May 2023.

Cost-effectiveness analysis of microwave ablation versus robot-assisted partial nephrectomy for patients with small renal masses in Australia

ObjectivesMicrowave ablation (MWA) has gained attention as a minimally invasive and safe alternative to surgical intervention for patients with small renal masses; however, its cost-effectiveness in Australia remains unclear. This study conducted a cost-effectiveness analysis to evaluate the relative clinical and economic merits of MWA compared to robotic-assisted partial nephrectomy (RA-PN) in the treatment of small renal masses. MethodsA Markov state-transition model was constructed to simulate the progression of Australian patients with small renal masses treated with MWA versus RA-PN over a 10-year horizon. Transition probabilities and utility data were sourced from comprehensive literature reviews, and cost data were estimated from the Australian health system perspective. Life-years, quality-adjusted life-years (QALYs), and lifetime costs were estimated. Modelled uncertainty was assessed using both deterministic and probabilistic sensitivity analyses. A willingness-to-pay (WTP) threshold of $50,000 per QALY was adopted. All costs are expressed in 2022 Australian dollars and discounted at 3% annually. To assess the broader applicability of our findings, a validated cost-adaptation method was employed to extend the analysis to 8 other high-income countries. ResultsBoth the base case and cost-adaptation analyses revealed that MWA dominated RA-PN, producing both lower costs and greater effectiveness over 10 years. The cost-effectiveness outcome was robust across all model parameters. Probabilistic sensitivity analyses confirmed that MWA was dominant in 98.3% of simulations at the designated WTP threshold, underscoring the reliability of the model under varying assumptions. ConclusionFor patients with small renal masses in Australia and comparable healthcare settings, MWA is the preferred strategy to maximize health benefits per dollar, making it a highly cost-effective alternative to RA-PN.

The key role of the most recent EU regulation – the “Digital Operational Resilence Act” in the legal system, contemporary challenges, and Georgian perspectives

The challenges of the modern world, such as globalization, digitalization, and other technological advances, have exposed all fields of science, including economics and law, to severe trials. The bold and visionary attempt of legislative bodies in various countries, to evaluate the advantages and disadvantages of existing regulations and consider new ones was complemented by the development of methods and mechanisms to oversee, regulate, and incorporate the latest technological advancements into the legal framework. After ineffective efforts to deal with various objections, the European Union adopted a new regulation called the "Digital Operational Resilience Act." This regulation aims to address the challenges presented by the increasing cybersecurity threats, operational resilience, and digitalization in the financial sector, both ex-ante and ex-post. In this paper, you will learn about the role of “DORA” in the legal system, the economic analysis of the law, the challenges it faces in the European Union, and the perspectives of the Georgian reality. This paper will employ qualitative and theoretical research methods, focusing on the in-depth analysis of existing legal frameworks and expert perspectives. These methods will allow for a comprehensive understanding of DORA's implications in both the European Union and the Georgian context, offering valuable insights into its potential effectiveness and challenges.

BIM IMPLEMENTATION FOR HERITAGE RENOVATION THROUGHOUT PROJECT LIFECYCLE: CURRENT USE, BENEFITS, AND BARRIERS

Introduction: Building Information Modeling (BIM) has garnered significant attention due to advancements in sophisticated technologies and methods. However, a comprehensive review of the existing literature indicates a lack of research exploring the application of BIM in managing the entire intervention design and renovation processes from a broader system perspective. The purpose of the study was to fill this gap by identifying and evaluating the current utilization, benefits, and barriers associated with implementing BIM in the lifecycle of renovation projects. The study methodology is based on conducting 31 structured interviews with experienced professionals who have employed BIM in their project deliveries. The results reveal that the primary benefits of BIM adoption, in descending order of importance, pertain to improved collective understanding of design intent, lower risk and better predictability of outcomes, better-designed and performing buildings, more accurate project documentation, and increased accuracy of the cost estimate. However, there are several prominent barriers: project budget, complexity of modeling historic structures, cost to hire BIM professionals, and the lack of BIM knowledge. The findings will advance BIM adoption for heritage renovation and enable project stakeholders to focus on realizing the benefits and potential uses of lifecycle BIM, while also addressing the critical challenges discussed in this study.

Education as an e-resilient system: Empirical insights from stakeholder perspectives in public affairs education

ABSTRACT This paper explores the concept of e-resilience in educational systems, particularly in Public Affairs Education, in response to the COVID-19 pandemic. We investigate the drivers and challenges faced by actors from an educational system perspective, which is conceptualized by adjusting Bronfenbrenners’ ecological model using dimensions of Technology, Human, and Intersections and levels Macro, Meso and Micro, during this global shock. Utilizing a multiple case study approach across Argentina, Nigeria, South Africa, the Netherlands, and the United States, we examine e-resilience through 36 group interviews involving 41 students, staff, administration, and program directors. Our findings reveal that challenges within the technological system impact overall system performance, while human-level challenges disrupt learning and pose greater obstacles for the system. Despite these challenges, each context exhibits various drivers, providing insights for building more robust educational systems. By better understanding the dynamics of e-resilience within each educational system context, we can enhance educational systems in the face of unprecedented shocks.

THE EXPRESSION OF EVALUATION IN “THE ULTIMATE GUIDE TO MUST-TRY INDONESIAN FOOD”: AN APPRAISAL ANALYSIS

Appraisal, under Systemic Functional Linguistics (SFL) especially interpersonal meaning, concerns with evaluation of language that is negotiated through the text (Martin and White, 2005; Martin and Rose, 2007). Briefly, appraisal is used to assess things, situation, or people. This study investigates the Journalist’s evaluation towards ten of most popular Indonesian savory foods across Indonesia from the perspective of appraisal system. Indonesia is a home for 300 ethnic groups, and it offers a wide range of culinary. In this study, the researcher limits the study on one type of attitudes subsystem namely appreciation. Appreciation is our evaluation about ‘things’, particularly thing we make and actions we give, and it also includes natural phenomenon (Martin and White, 2005; Martin and Rose, 2007, Santosa, et.al, 2023). This study employs qualitative research using a criterion-based sampling technique known as purposive sample and content analysis for the technique of data analysis (Santosa, 2017). The source of data in this study was a document that consists of 10 must-try savory Indonesian foods which was retrieved from an Indonesia travel website https://www.indonesia.travel/sg/en/home. Thus, the data were segmented into types of appreciation such as reaction: impact and quality, composition: balance and complexity, and valuation. Furthermore, in analyzing the data, the researcher applies appraisal theoretical framework developed by Martin and White (2005). The results of this study show that the most dominant type of appreciation exploited by the journalist is positive valuation. It is used to show the journalist’s appreciation and critics to the foods he reviewed. The following clause is the example of the finding ‘Rendang, an authentic Indonesian dish from Padang’. The bold lexis is used by the journalist to show his appreciation towards the typical food from Pandang, West Sumatra, Indonesia called Rendang. It indicates that the journalist expresses his positive valuation to some foods he reviewed to evoke people’s appetites and to invite them to try some authentic Indonesian foods. Moreover, the result of this study is in line with the research conducted by Daniarsa & Ningsih (2023) about tendency in Indonesian newspaper editorials. The result of the study indicates that the tendency of using positive appreciation is to give implicit and explicit praise and assessment to Jokowi and his vice’s leadership. Meanwhile, the finding also supports research carried out by Wu & Pan (2021) who also stated that the use of positive appreciation is to express the journalist’s wishes or appreciation towards the ‘things’ he wrote about.

Cost-effectiveness of MLC601 in post-stroke functional recovery compared with placebo - the CHIMES & CHIMES-E studies

BackgroundDespite progress in stroke therapy (e.g., revascularisation interventions by thrombolysis and/or thrombectomy, organised stroke care), many stroke survivors will have impairment of neurological function. We aimed to compare the cost-effectiveness of an oral natural formulation, MLC601, versus placebo in functional recovery among subjects receiving standard of care after an ischemic stroke of intermediate severity assessed with NIH Stroke Scale at baseline (b-NIHSS 8–14).MethodsA Markov cohort model with a 2-year time horizon was developed to simulate patients from a published randomised placebo-controlled clinical trial of MLC601 in their post-stroke functional recovery assessed by modified Rankin Score (mRS), from a health system perspective. Transition probabilities were derived from a multi-centre clinical trial in South East Asia. As cost and utility data were not collected in the trial, therefore we extracted them from the published literature. The main outcomes were incremental cost, incremental quality-adjusted life-year (QALY) gained, and incremental cost-effectiveness ratio (ICER). Besides base-case and sensitivity analyses, we performed subgroup analyses to explore the heterogeneity of patients with poor-prognosis factors (b-NIHSS 10–14, stroke onset to treatment time > 48 h, rehabilitation during first 3 month). All costs are expressed in 2022 Euro and USD, with an annual discount rate of 3% applied to costs and QALYs.ResultsBase-case analysis showed that MLC601 was cost-effective compared with placebo, with €5,080 saved and 0.45 QALY gained, resulting in an ICER of -€11,352.50 per QALY gained. Similarly, results from subgroup analyses indicated that the use of MLC601 was a dominant strategy in all subgroups with poor-prognosis factors. Sensitivity analyses revealed the results were robust.ConclusionCompared with placebo on top of standard stroke care, MLC601 was cost-effective in post-stroke functional recovery over two years. Due to the lack of cost and utility data from the study population, the results might not be generalizable to other settings. Further studies with country-specific data are needed to confirm the results of this study.Trial registrationURL http://www.clinicaltrials.gov. Unique identifier NCT00554723 November 7, 2007.

Sensor self-diagnosis method for a nickel top-blowing furnace based on graph interactive dynamic fusion

Abstract As modern industry gradually advances towards greater automation and intelligence, the scale of nickel top-blowing furnace smelting systems is continuously expanding, leading to an increasing need for sensor maintenance. Traditional periodic evaluations and manual maintenance methods are no longer sufficient to meet the development needs of intelligent sensors. To address this issue, this paper proposes a sensor self-diagnosis method based on graph interactive dynamic fusion, called DLGCN-GIDF. First, a combination of knowledge-driven and data-driven approaches is introduced. By constructing a dual-layer architecture based on a functional module graph network and a sensor graph network, a sensor correlation graph model for the nickel top-blowing furnace system is established. Next, with the aid of a GIDF module, the relative weights between functional modules and sensors are integrated to perform spatiotemporal correlation-based graph fusion. This enables the prediction of spatiotemporal data for sensors from a system perspective. Finally, the goal of sensor self-diagnosis is achieved using a standardised residual testing algorithm. Taking a nickel top-blowing furnace smelting system as an example, the feasibility and effectiveness of our method of sensor fault self-diagnosis are verified.

Digital health and equitable access to care.

Research on digital health equity has developed in important ways especially since the onset of the COVID-19 pandemic, with a series of clear recommendations now established for policy and practice. However, research and policy addressing the health system dimensions of digital health equity is needed to examine the appropriate roles of digital technologies in enabling access to care. We use a highly cited framework by Levesque et al on patient-centered access to care and the World Health Organization's framework on digitally enabled health systems to generate insights into the ways that digital solutions can support access to needed health care for structurally marginalized communities. Specifically, we mapped the frameworks to identify where applications of digital health do and do not support access to care, documenting which dimensions of access are under-addressed by digital health. Our analysis suggests that digital health has disproportionately focused on downstream enablers of access to care, which are low-yield when equity is the goal. We identify important opportunities for policy makers, funders and other stakeholders to attend more to digital solutions that support upstream enablement of peoples' abilities to understand, perceive, and seek out care. These areas are an important focal point for digital interventions and have the potential to be more equity-enhancing than downstream interventions at the time that care is accessed. Overall, we highlight the importance of taking a health system perspective when considering the roles of digital technologies in enhancing or inhibiting equitable access to needed health care.

Shared business understanding and innovation: The role of firm dominant logic in business model innovation

Business model innovation (BMI) is a key source of innovation that may create a competitive advantage for firms. Drawing insights from the activity system perspective of BMI and dynamic managerial capabilities literature, we argue that a firm's dominant logic promotes BMI, which in turn influences firm performance. We further investigate the boundary condition of managerial connections as providers of privileged resources and information. We examine the proposed hypotheses on a sample of 189 Chinese firms. Our findings suggest that firm dominant logic facilitates both novelty- and efficiency-centered BMI. Further, the two types of BMI affect firm performance differently. Specifically, efficiency-centered BMI improves performance, but novelty-centered BMI does not. In addition, managerial connections strengthen the effect of firm dominant logic on novelty-centered BMI but do not significantly influence the effect of efficiency-centered BMI, reflecting differences between novelty-centered and efficiency-centered BMI. This study is thus noteworthy in its contribution to both the BMI and dynamic capabilities literature.

Coevolutionary dynamics in tropical peat ecosystems: A case study of Sumatra peatlands biosphere reserve

Tropical peat swamp is an essential ecosystem experiencing increased degradation over the past few decades. Therefore, this study used the social-ecological system (SES) perspective to explain the complex relationship between humans and nature in the Sumatran Peatlands Biosphere Reserve. The peat swamp forest has experienced a significant decline, followed by a significant increase in oil palm and forest plantations in areas designated for peat protection. Human systems have evolved to become complex and hierarchical, constituting individuals, groups, organizations, and institutions. Studies on SES conducted in the tropical peatlands of Asia have yet to address the co-evolutionary processes occurring in this region, which could illustrate the dynamic relationship between humans and nature. This study highlights the co-evolutionary processes occurring in the tropical peatland biosphere reserve and provides insights into their sustainability trajectory. Moreover, the coevolution process shows that biosphere reserve is shifting toward an unsustainable path. This is indicated by ongoing degradation in three zones and a lack of a comprehensive framework for landscape-scale water management. Implementing landscape-scale water management is essential to sustain the capacity of peatlands social-ecological systems facing disturbances, and it is important to maintain biodiversity. In addition, exploring alternative development pathways can help alter these trajectories toward sustainability.