Abstract
There is a significant need for reforming healthcare systems in most contexts worldwide, and radical proposals based on complexity science and systems thinking are necessary. Health systems around the world are failing on three fronts – they fail to meet the needs of people/patients, they are disease-focused rather than health centered, and they are economically unsustainable.
Failed/failing systems cannot be reformed by incremental cost-management or policy changes; they need to be redesigned based on peoples/patients’ needs – these are far broader than disease-specific management and include social, community, work, and environmental domains. Embracing these insights is a major challenge for policy makers, not only do they have to convey the direction, they also have to facilitate the necessary adaptive work required by a large and diverse workforce within the health system and its institutions.
Health system redesign, while not easy, is possible. The organizational change management literature provides the foundations to lead the process, and the complex adaptive systems literature provides the conceptual understanding of the dynamic interdependencies within and across the organizational scales of the health system. And finally, there are a number of examples that can guide the redesign process toward effective, efficient, and sustainable health systems.
This is a preview of subscription content, log in via an institution to check access.
References
Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B (2012) Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 380(9836):37–43. https://doi.org/10.1016/s0140-6736(12)60240-2
Begun JW, Zimmerman B, Dooley K (2003) Health care organizations as complex adaptive systems. In: Mick SM, Wyttenbach M (eds) Advances in health care organization theory. Jossey-Bass, San Francisco, pp 253–288
Bennett JM, Reeves G, Billman G, Sturmberg JP (2018) Inflammation, nature’s way to efficiently respond to all types of challenges: implications for understanding and managing “the epidemic” of chronic diseases. Frontiers in Medicine 5:316. https://doi.org/10.3389/fmed.2018.00316
Benyamini Y (2011) Why does self-rated health predict mortality? An update on current knowledge and a research agenda for psychologists. Psychol Health 26(11):1407–1413. https://doi.org/10.1080/08870446.2011.621703
Berwick D (1998) Developing and testing changes in delivery of care. Ann Intern Med 128(8):651–656. https://doi.org/10.7326/0003-4819-128-8-199804150-00009
Bloom G, Wolcott S (2013) Building institutions for health and health systems in contexts of rapid change. Soc Sci Med 96:216–222. https://doi.org/10.1016/j.socscimed.2012.12.014
Borgermans L, De Maeseneer J, Wollersheim H, Vrijhoef B, Devroey D (2013) A theoretical Lens for revealing the complexity of chronic care. Perspect Biol Med 56(2):289–299. https://doi.org/10.1353/pbm.2013.0017
Chen L, Evans T, Anand S, Boufford JI, Brown H, Chowdhury M, … Wibulpolprasert S (2004) Human resources for health: overcoming the crisis. Lancet 364(9449):1984–1990. https://doi.org/10.1016/S0140-6736(04)17482-5
Chen DT, Werhane PH, Mills AE (2007) Role of organization ethics in critical care medicine. Crit Care Med. Organizational and Management Ethics in the Intensive Care Unit 35(2):S11–S17. https://doi.org/10.1097/01.CCM.0000252913.21741.35
Cloninger, CR, Salvador-Carulla L, Kirmayer LJ, Schwartz MA, Appleyard J, Goodwin N, … Rawaf S (2014) A time for action on health inequities: foundations of the 2014 Geneva declaration on person- and people-centered integrated health care for all. Int J Pers Centered Med 4(2):69–89
Collins B (2015) Intentional whole health system redesign. Southcentral Foundation’s ‘Nuka’ system of care. London: King’s Fund, 2015. https://www.kingsfund.org.uk/publications/intentional-whole-health-system-redesign-nuka-southcentral. Last accessed: 29-Jun-2020
Conklin J (2020) Wicked Problems & Social Complexity. CogNexus Institute, 2010. https://cognexus.org/wpf/wickedproblems.pdf. Last accessed: 29-Jun-2020
Dhonden LY (1974) Tibetan medicine: a short history. Tibetan Rev May–June:13
Ellis GFR (2012) Top-down causation and emergence: some comments on mechanisms. Interface Focus 2(1):126–140. https://doi.org/10.1098/rsfs.2011.0062
Franceschi C, Capri M, Monti D, Giunta S, Olivieri F, Sevini F, … Salvioli S (2007) Inflammaging and anti-inflammaging: a systemic perspective on aging and longevity emerged from studies in humans. Mech Ageing Dev 128(1):92–105. https://doi.org/10.1016/j.mad.2006.11.016
Freedman LP, Schaaf M (2013) Act global, but think local: accountability at the frontlines. Reprod Health Matters 21(42):103–112. https://doi.org/10.1016/S0968-8080(13)42744-1
Fulop L, Mark A (2013) Relational leadership, decision-making and the messiness of context in healthcare. Leadership 9(2):254–277. https://doi.org/10.1177/1742715012468785
Gilson L, Elloker S, Olckers P, Lehmann U (2014) Advancing the application of systems thinking in health: south African examples of a leadership of sensemaking for primary health care. Health Res Policy Syst 12(1):30. https://doi.org/0.1186/1478-4505-12-30
Glouberman S, Zimmerman B (2002) Complicated and Complex Systems: What Would Successful Reform of Medicare Look Like? Ottawa: Discussion Paper No 8. Commission on the Future of Health Care in Canada. https://www.alnap.org/system/files/content/resource/files/main/complicatedandcomplexsystems-zimmermanreport-medicare-reform.pdf. Last accessed: 29-Jun-2020
Gottlieb K (2013) The Nuka system of care: improving health through ownership and relationships. Int J Circumpolar Health 72:10.3402/ijch.v3472i3400.21118. https://doi.org/10.3402/ijch.v72i0.21118
Green L, Fryer G, Yawn B, Lanier D, Dovey S (2001) The ecology of medical care revisited. N Engl J Med 344(26):2021–2025. https://doi.org/10.1056/NEJM200106283442611
Heifetz R (1994) Leadership without easy answers. Harvard University Press, Cambridge, MA
Heifetz R, Grashow A, Linsky M (2009) The practice of adaptive leadership: tools and tactics for changing your organization and the world. Harvard Business Press, Boston
Ho S, Sandy L (2014) Getting value from health spending: going beyond payment reform. J Gen Intern Med 29(5):796–797. https://doi.org/10.1007/s11606-013-2687-7
Hosking D (1988) Organizing, leadership and skillful process. J Manag Stud 25(2):147–166. https://doi.org/10.1111/j.1467-6486.1988.tb00029.x
Hosking D, Fineman S (1990) Organizing processes. J Manag Stud 27(6):583–604. https://doi.org/10.1111/j.1467-6486.1990.tb00264.x
Johansen ME, Kircher SM, Huerta TR (2016) Reexamining the ecology of medical care. N Engl J Med 374(5):495–496. https://doi.org/10.1056/NEJMc1506109
Jylhä M (2009) What is self-rated health and why does it predict mortality? Towards a unified conceptual model. Soc Sci Med 69(3):307–316. https://doi.org/10.1016/j.socscimed.2009.05.013
Kaplan RS, Porter ME (2011) How to solve the cost crisis in health care. Harv Bus Rev 89(9):47–64
Khalsa SS, Lapidus RC (2016) Can Interoception improve the pragmatic search for biomarkers in psychiatry? Front Psych 7(121). https://doi.org/10.3389/fpsyt.2016.00121
Kolko J (2015) Design thinking comes of age. Harv Bus Rev 93(9):66–69
Kottke TE (2013) Simple rules that reduce hospital readmission. Perm J 17(3):91–93. https://doi.org/10.7812/TPP/13-024
Kurtz CF, Snowden DJ (2003) The new dynamics of strategy: sense-making in a complex and complicated world. IBM Syst J 42(3):462–483. https://doi.org/10.1147/sj.423.0462
Lehmann U, Sanders D (2007) Community health workers: What do we know about them? Geneva: World Health Organisation. http://www.who.int/hrh/documents/community_health_workers.pdf. Last accessed: 29-Jun-2020
Lindstrom R (2003) Evidence-based decision-making in healthcare: exploring the issues through the lens of complex, adaptive systems theory. Healthc Pap 3(3):29–35. https://doi.org/10.12927/hcpap..17127
Marchal B, Van Belle S, De Brouwere V, Witter S (2013) Studying complex interventions: reflections from the FEM health project on evaluating fee exemption policies in West Africa and Morocco. BMC Health Serv Res 13(1):469. https://doi.org/10.1186/1472-6963-13-469
Martin CM, Sturmberg JP (2006) Rethinking general practice – part 2: strategies for the future. Patient-Centred, socially and economically responsible primary care and the leadership challenges. Asia Pac Fam Med 5(5). www.apfmj-archive.com/afm5_2/afm48.pdf
Martin CM, Felix Bortolotti M (2010) W(h)ither complexity? The emperor’s new toolkit? Or elucidating the evolution of health systems knowledge? J Eval Clin Pract 16(3):415–420. https://doi.org/10.1111/j.1365-2753.2010.01461.x
Martin D, Pollack K, Woollard RF (2014) What would an Ian McWhinney health care system look like? Can Fam Physician 60(1):17–19
McWhinney IR (1989) An acquaintance with particulars …. Fam Med 21(4):296–298
Njoroge A, Cassidy S, Williams V (2013) Making patient-centred care a reality in the slums of eastern Nairobi. Int J Tuberc Lung Dis 17(10 (Suppl 1)):5–8. https://doi.org/10.5588/ijtld.13.0186
Paina L, Peters DH (2012) Understanding pathways for scaling up health services through the lens of complex adaptive systems. Health Policy Plan 27(5):365–373. https://doi.org/10.1093/heapol/czr054
Plsek P (2001) Appendix B: redesigning health care with insights from the science of complex adaptive systems. In: Committee on Quality of Health Care in America – Institute of Medicine (ed) Crossing the quality chasm: a new health system for the 21st century. National Academy Press, Washington, DC, pp 309–322
Pourbohloul B, Kieny M-P (2011) Complex systems analysis: towards holistic approaches to health systems planning and policy. World Health Org Bull World Health Org 89(4):242. https://doi.org/10.2471/BLT.11.087544
Prashanth N, Marchal B, Devadasan N, Kegels G, Criel B (2014) Advancing the application of systems thinking in health: a realist evaluation of a capacity building programme for district managers in Tumkur, India. Health Res Policy Syst 12(1):42. https://doi.org/10.1186/1478-4505-12-42
Rittel HWJ, Webber MM (1973) Dilemmas in a general theory of planning policy sciences. Policy Sci 4(2):155–169. https://doi.org/10.1186/1478-4505-12-42
Rogers KH, Luton R, Biggs H, Biggs R, Blignaut S, Choles AG, … Tangwe P (2013) Fostering complexity thinking in action research for change in social-ecological systems. Ecol Soc 18(2):31. https://doi.org/10.5751/ES-05330-180231
Rouse WB (2008) Health care as a complex adaptive system: implications for design and management. Bridge 38(1):17–25. https://www.nae.edu/7704/HealthCareasaComplexAdaptiveSystemImplicationsforDesignandManagement. Last accessed: 29-Jun-2020
Saxton JF, Johns MME (2010) Barriers to change in engineering the system of health care delivery. In: Engineering the system of healthcare delivery, vol 153. IOS Press, Amsterdam, pp 437–463. https://doi.org/10.3233/IKS-2009-0150
Sedivy R (2004) 200 Jahre Rokitansky – sein Vermächtnis für die heutige Pathologie. Wien Klin Wochenschr 116(23):779–787. https://doi.org/10.1007/s00508-004-0272-0
Simon HA (1996) The Sciences of the artificial, 3rd edn. MIT Press, Cambridge, MA
Stewart AL, Hays RD, Ware JE (1988) The MOS short-form general health survey: reliability and validity in a patient population. Med Care 26(7):724–735. https://doi.org/10.1097/00005650-198807000-00007
Stewart AL, Greenfield S, Hays RD, Wells K, Rogers WH, Berry SD, … Ware JE (1989) Functional status and Well-being of patients with chronic conditions. Results from the medical outcomes study. J Am Med Assoc 262(7):907–913
Sturmberg JP (2009) The personal nature of health. J Eval Clin Pract 15(4):766–769. https://doi.org/10.1111/j.1365-2753.2009.01225.x
Sturmberg JP (2013) Health: a personal complex-adaptive state. In: Sturmberg JP, Martin CM (eds) Handbook of systems and complexity in health. Springer, New York, pp 231–242. https://doi.org/10.1007/978-1-4614-4998-0_15
Sturmberg JP (2014) Emergent properties define the subjective nature of health and disease. J Public Health Policy 35(3):414–419. https://doi.org/10.1057/jphp.2014.20
Sturmberg JP (2018a) Health system redesign. How to make health care person-centered, equitable, and sustainable. Springer, Cham
Sturmberg JP (2018b) Time to design a “real health system”. BMJ 361:k2598. https://doi.org/10.1136/bmj.k2598
Sturmberg JP (2019) Person-centeredness – a paradigm shift for health care? From disease as a “structural problem” to health, illness and disease as the “emergent outcomes of complex adaptive physiological network function”. Accepted manuscript
Sturmberg JP, Martin CM (2010) The dynamics of health care reform – learning from a complex adaptive systems theoretical perspective. Nonlinear Dynamics Psychol Life Sci 14(4):525–540
Sturmberg JP, Martin CM (2013) Complexity in health: an introduction. In: Sturmberg JP, Martin CM (eds) Handbook of systems and complexity in health. Springer, New York, pp 1–17. https://doi.org/10.1007/978-1-4614-4998-0_1
Sturmberg JP, Njoroge A (2017) People-centred health systems, a bottom-up approach: where theory meets empery. J Eval Clin Pract 23(2):467–473. https://doi.org/10.1111/jep.12540
Sturmberg JP, O’Halloran DM, Martin CM (2010) People at the Centre of complex adaptive health systems reform. Med J Aust 193(8):474–478. https://doi.org/10.5694/j.1326-5377.2010.tb04004.x
Sturmberg JP, O’Halloran DM, Martin CM (2012) Understanding health system reform – a complex adaptive systems perspective. J Eval Clin Pract 18(1):202–208. https://doi.org/10.1111/j.1365-2753.2011.01792.x
Sturmberg JP, O’Halloran DM, Martin CM (2013) Health care reform – the need for a complex adaptive systems approach. In: Sturmberg JP, Martin CM (eds) Handbook of systems and complexity in health. Springer, New York, pp 827–853. https://doi.org/10.1007/978-1-4614-4998-0_47
Sturmberg JP, Bennett JM, Martin CM, Picard M (2017) ‘Multimorbidity’ as the manifestation of network disturbances. J Eval Clin Pract 23(1):199–208. https://doi.org/10.1111/jep.12587
Sturmberg JP, Picard M, Aron DC, Bennett JM, Bircher J, deHaven MJ, … Melis RJF (2019) Health and disease – emergent states resulting from adaptive social and biological network interactions. Front Med 6:59. https://doi.org/10.3389/fmed.2019.00059
Swanson R, Atun R, Best A, Betigeri A, de Campos F, Chunharas S, … Van Damme W (2015) Strengthening health systems in low-income countries by enhancing organizational capacities and improving institutions. Glob Health 11(1):5. https://doi.org/10.1186/s12992-015-0090-3
Tissue T (1972) Another look at self-rated health among the elderly. J Gerontol 27(1):91–94. https://doi.org/10.1093/geronj/27.1.91
Tsasis P, Evans JM, Owen S (2012) Reframing the challenges to integrated care: a complex-adaptive systems perspective. Int J Integr Care 12(e190). https://doi.org/10.5334/ijic.843
van der Vlegel-Brouwer W (2013) Integrated healthcare for chronically ill. Reflections on the gap between science and practice and how to bridge the gap. Int J Integr Care 13:e019. https://doi.org/10.5334/ijic.1079
Varghese J, Kutty V, Paina L, Adam T (2014) Advancing the application of systems thinking in health: understanding the growing complexity governing immunization services in Kerala, India. Health Res Policy Syst 12(1):47. https://doi.org/10.1186/1478-4505-12-47
White K, Williams F, Greenberg B (1961) The ecology of medical care. N Engl J Med 265(18):885–892. https://doi.org/10.1056/NEJM196111022651805
WHO – Western Pacific Region (2007) People at the Centre of Health Care. Harmonizing mind and body, people and systems. Geneva: WHO Western Pacific Region. https://iris.wpro.who.int/handle/10665.1/5416. Last accessed: 29-Jun-2020
Author information
Authors and Affiliations
Editor information
Editors and Affiliations
Section Editor information
Rights and permissions
Copyright information
© 2020 Springer Nature Singapore Pte Ltd.
About this entry
Cite this entry
Sturmberg, J.P. (2020). Systems Design for Health System Reform. In: Metcalf, G., Kijima, K., Deguchi, H. (eds) Handbook of Systems Sciences. Springer, Singapore. https://doi.org/10.1007/978-981-13-0370-8_56-1
Download citation
DOI: https://doi.org/10.1007/978-981-13-0370-8_56-1
Received:
Accepted:
Published:
Publisher Name: Springer, Singapore
Print ISBN: 978-981-13-0370-8
Online ISBN: 978-981-13-0370-8
eBook Packages: Springer Reference Business and ManagementReference Module Humanities and Social SciencesReference Module Business, Economics and Social Sciences