One of the biggest stories this week is that US President Barack Obama has signed a landmark healthcare bill into law – the largest expansion of the US federal social safety net since the 1960s. But work by leading healthcare analysts around the world would indicate that the safe passage of the bill is only the starting point.

In a paper for the Commission on the Future of Healthcare, Sholom Glouberman and Brenda Zimmerman illustrate how attempts to intervene in complex health care systems often treat them as if they were merely complicated, or even worse, simple.

The table below sets out the now well-known framework which they use to make these distinctions. Glouberman and Zimmerman argue that such conceptual mismatches between reforms and reality can compound healthcare failures in dramatic ways. They give a number of examples of how this has happened in the Canadian Medicare system.

The authors liken the pervasiveness of existing ‘complicated’ approaches to healthcare reforms to an often-told story of a man who is stumbling around near a lamppost:

…He is asked what he is doing and says that he is looking for his car keys. “Oh, where do you think you lost them?”
“Down the block near my car,” he says.
“So why are you looking for them here?”
“Because the light is better.”

They continue:

The sophistication of our models, theories and language for complicated problems can be as seductive as the lamplight. They provide better “light” and clarity and yet can lead to approaches that are ill-equipped to address complex adaptive systems…” (emphasis added)

They aren’t the only ones to see potential for complexity science in bringing about healthcare improvements. Paul Plesk, Director of the Academy for Large Scale Change at the UK’s NHS Institute of Innovation, uses the same distinction between complicated and complex systems as a way of demonstrating how ‘directed creativity’ can be utilised in change processes. The World Health Organization has also been using complexity approaches in its work on knowledge management, and on analysing disrupted health systems in conflict-affected countries.

The Healthcare Commission paper sets out four clusters of differences between complicated and complex systems, all of which  have relevance for healthcare reforms.

Theory of systems First, the theory of health systems is enhanced by ideas of real-world systems which behave in nonlinear and  unpredictable ways. It isn’t just a case of pulling levers, and ignoring noise and fluctuations. Instead, the key is to embrace uncertainty, tension, noise – to work with these factors as givens rather than as aberrations.

Causality The second set of differences is about how change happens, specifically how causality is not one-way but dynamic with multiple feedback processes. This means accepting dynamics of change as two-way, unpredictable and never-ending:

Evidence The third set of differences relates to evidence, and how complexity means that certain kinds of evidence – much of which would be dismissed if health systems were seen as merely complicated – needs to be understood. Specifically: outliers, historical anomalies, and patterns of behavior and relationships all need to be examined and understood.

Planning and decision-making The fourth area relates to planning and decision making, and how overall system-wide properties emerge from many small-scale decisions. Therefore the key is not to plan everything in advance, but to put in place a process of strategic learning that will allow for corrections, shifts, and even wholesale changes in approach.

A number of case study examples are cited in Healthcare Commission paper, with the two most detailed ones covering the French healthcare system, which was ranked best in the world by the WHO in 2009; and the Brazillian healthcare system, specifically in relation to the HIV-AIDS response in the 1990s.
Both of these case studies illustrate how the approaches taken to theory, causality, evidence and planning were different to those suggested by a ‘complicated’ view of the world, and were also more successful in terms of health outcomes in those countries. Especially interesting for all those interested in complexity in aid is the account of how, in the Brazil HIV-AIDS case, a complicated worldview was heavily pushed by external aid actors (notably the World Bank), and was rejected by the Brazil government in favour of a more complexity-oriented perspective.
These ideas would appear to be highly relevant for the effective implementation of the new US bill. The challenge faced is three-fold:
  • to articulate an approach to the complex issues faced in changing healthcare systems
  • to resist the technical bias to analysis which assumes the problem is a complicated one
  • to resist political influences that promote particular approaches and mindsets, and reduces engagement with complexity
This last issue is perhaps the critical one in the current US context. As the World Bank-Brazilian Government example illustrates, political context is vital in enabling these challenges to be addressed. In the USA, there has been widespread opposition to the bill, and vehement calls for the bill to be scrapped. The implementers will be under enormous pressure at all stages to demonstrate the bill is working – ambiguity will not be tolerated, and the smallest sign of failure will be picked up to score political points.

In the face of such vociferous opposition, the need to question existing assumptions and mindsets may seem irrelevant. But it is arguably even more important in such settings. As Muhammed Yunus, founder of Grameen Bank, put it recently, when talking about the rise of microfinance: “[the] greatest challenge has been to change the mindset of people.”

In this light, perhaps the true test of the healthcare reforms will not merely be new legislation, budget and policy frameworks, technical fixes, unseen compromises and political victories. Perhaps the true test of the reforms will be whether they bring about change in mindsets.


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  1. […] specialist whose work on health systems has featured on two previous Aid on the Edge posts (here and […]


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About Ben Ramalingam

I am a researcher and writer specialising on international development and humanitarian issues. I am currently working on a number of consulting and advisory assignments for international agencies. I am also writing a book on complexity sciences and international aid which will be published by Oxford University Press. I hold Senior Research Associate and Visiting Fellow positions at the Institute of Development Studies, the Overseas Development Institute, and the London School of Economics.


Healthcare, Public Policy, Reports and Studies, Strategy