Complexity in health care

“Complexity” is a term understood in different ways. It has a long history in fields like systems theory, artificial intelligence and mathematics. It has been taken up much more slowly in medicine, public health and health systems research. In these domains, there is still some important conceptual confusion around the definition of ‘complexity’.

Only a few publications bridge complexity theory and organisation of health care in a useful manner. Complexity was taken up more rapidly by the evaluation community and many interesting insights originate from that field. Also in the domain of management, complexity became a prominent topic in the 1990s.

Example of a model linking management practices to organisational performance:

In health systems, complexity can be applied to (1) organisations, (2) problems and (3) policies, management interventions and programmes.

Health care organisations are complicated systems

They are staffed by cadres having their specific competences, cultures and shared mental models.
They are made up by different units and levels.
Staff and units relate and interact to each other through formal and informal channels.
Each unit is dealing with different tasks and specialised functions, but all units need to be working towards the shared goal of providing care to patients.

Health care organisations are also complex systems

It is the actors’ “agency” at work in social relationships and feedback mechanisms that make health care organisations complex.

Interactions lead to new unpredictable actions of the actors (emergence).
But these emergent behaviours are somehow restricted by the history (path dependency) and the “structure” (formal and informal rules) of the organisation.

Sturmberg and Martin (2009) present a concise overview of how health care has all the characteristics of complex systems, with both clinical and health care organisation examples.

Problems or situations can be complex

Problems or situations are complex if they are determined by multiple, interacting factors. The people involved, their interactions and the specific context they live and work in shape webs of connections and relations. The interactions may involve positive or negative feedback loops. Understanding such complex situations requires the disentangling of intervention, actors, mechanisms of change, outcome and context.

Some policies, management interventions and programmes are complex

Health policies, management interventions and programmes are complex if

they consist of various parts that interact with each other in non-linear, unpredictable ways
the underlying mechanism of change has a complex nature or is unknown

Hill (2010) applied complex systems thinking to global policy.

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TDI workshop

On 22 and 23 November 2010, the Unit of Health Care Management, Department of Public Health (ITM), organised an international expert meeting on theory-driven evaluation.

About 15 researchers presented research and evaluations and discussed the methodological challenges of realist evaluation, theory-driven evaluation and realist synthesis in health systems research.

In total 30 researchers, policymakers and programme managers attended the workshop.

About this website

This theory-driven inquiry website is developed by the Health Care Management Unit of the Department of Public Health, Institute of Tropical Medicine, Antwerp and the Development Policy & Practice Unit of the Royal Tropical Institute, Amsterdam. We collaborate on the development and implementation of theory-driven inquiry in health systems research, and aim at stimulating a better understanding of the advantages of this approach among both researchers and policymakers. To this end, we are engaged in a number of research and evaluation studies that use TD inquiry principles.