Complexity and Health

Complexity & Health unit

We aim at developing better knowledge on how actors (need to) transform their health services, programmes and systems in response to the effects of climate change and urbanisation. Our methodological agenda aims at developing better knowledge production methods (incl. analytical approaches and data collection methods) to deal with causal complexity.

In our research, we apply the Ecohealth principles and specifically complex systems theory. We work closely with our colleagues of the EcoHealth Research Group and co-lead the Thematic Global Network Climate change, urbanisation and health (EcoHub).

Research themes

1. Resilience of health systems

We examine what resilience of health systems means, how it is defined (and contested), the factors that shape resilience and how it can be assessed. We frame this in social-ecological systems theory. We adopt a multiscale perspective that links individual, community, organisational and system resilience. We are particularly interested in transformation of health systems and the conditions that are required to induce structural (social) change.  

• Kirsten Accoe and colleagues examined the response of local health system actors to the Covid-19 pandemic in Mauretania from a health system resilience perspective.
• Orawan Tawaytibhongs, Bruno Marchal and Joris Michielsen are looking at the effect of serial shocks on the resilience of local health systems in two districts in Thailand.
• Joris Michielsen is studying the resilience of social protection and health financing systems in low- and middle-income countries and how social health protection can contribute to the resilience of vulnerable communities and people.

2. Urban health systems

Considering cities as complex social systems, we explore the relationship between multi-level governance and the organisation of urban health systems. We are interested in the conditions of success of co-production of urban (health) policies and in how health urban system actors move from adaptation to shocks (incl. climate change) to effective transformation of their health systems.

• In recent projects, Tom Cornu, Bruno Marchal and Joris Michielsen, together with Sara Van Belle and colleagues from the University of Antwerp examined how actors in urban first line health zones in Flanders and in Kinshasa responded to the Covid-19 pandemic.
• In a ITM DataHub project, Joris Michielsen, Tom Cornu, Guillermo Hegel and Bruno Marchal are examining how urban actors collect, interpret and use data in processes of health policymaking and governance in Antwerp and Lima.
• Houssynatou Sy; Joris Michielsen and Bruno Marchal focus on how internally displaced people moved with their livestock to informal settlements in Bamako (Mali) and how they deal with health problems and health care in the context of informal urban settlements. 

3. The effects of climate change

• In his PhD study, Tom Cornu focuses on the relationship between green prescription for elderly people,the use of urban green spaces and resilience. 
• Karen Ceballos and Joris Michielsen examine, together with colleagues from ITM’s Pharmaceutical Public Health Unit and the Emerging Infectious Diseases unit, how globally formulated ethical guidelines for research on climate change are perceived and experienced by communities exposed to extreme weather due to climate change.

Research methodology 

We explore, develop and apply methods that address complex causation in health.

1. Realist evaluation and research

Since more than 20 years, we are advancing the application of realist evaluation and research in the field of health system and policy research. We are currently interested in, analysing interdependent and co-occurring processes and events, the interaction between context and mechanisms and the dimension of time. 

• Virginia Castellano Pleguezuelo focuses her PhD research on how realist evaluation deals with complexity and the usefulness of academic research for decision-makers who are confronted with complex issues.
• Nandini Sarkar applied realist evaluation in the Afya-Tec projects which focus on the implementation and scaling up of people-centred digitised primary health care systems in Kibaha, Tanzania. 
• Together with Sara Van Belle, we explore how Margaret Archer’s Structure Agency Culture framework can be used in realist evaluation and research.

2. Co-creation

Co-production of knowledge and policies is a central element of many of our current projects. We examine the conditions in which co-production of knowledge is possible, effective and contributing to better decisions and reducing inequity.

• In the Youth-centred participatory action project (YOPA), which focuses on the multifaceted challenges of physical inactivity and health inequalities, Sara Van Belle, Virginia Plezueguelo and Bruno Marchal lead a realist evaluation of the co-producton processes in Denmark, the Netherlands, Nigeria and South Africa.
• Joris Michielsen and Houssynatou Sy explore the minimal conditions and ethical challenges of co-creation with vulnerable people in fragile settings.
• Joris Michielsen, Tom Cornu, Guillermo Hegel and Bruno Marchal examine how actors in Antwerp and Lima use data in the development and implementation of urban health policies. The focus is on co-development of scenarios with urban health system actors to study how data are used in the decision-making related to climate change.
• Virginia Castellano Pleguezuelo and Bruno Marchal used realist evaluation to assess a co-produced intervention to improve quality of care in maternities within the ALERT project.
• Tom Cornu, with Joris Michielsen and Bruno Marchal, currently co-produces a green prescription intervention for elderly people in Mechelen and Antwerp.

3. Multi-scale / multi-level analysis

We seek to develop or finetune methods to describe concurring causal pathways that involve events and outcomes at different levels in a system. We are interested in how quantitative methods can be integrated with qualitative data in this process. We have a strong interest in exploring how time and place has been conceptualised and operationalised in methods and methodologies in evaluations and research.

Education 

The unit has a large education portfolio.

• MSc Public Health, ITM: we currently lead the advanced course components Health Systems Research Methods, Health system performance analysis and Health System Strengthening. We contribute to Core Component 1 Health Systems and Policy, and the ACC Sustainable approaches to disease control and elimination course
• We contribute to the Postgraduate course Challenges in international Health (CIH)
• We currently supervise 8 PhD students.
• Bruno Marchal was Director of the post graduate course (IIH) till 2022 and is since then director of the MSc Public Health.

International cooperation

We co-lead the Thematic Global Network Climate change, urbanisation and health (EcoHub), which connects ITM partners across the world through small projects, webinars and exchange projects.

We work with policymakers, such as the Federal Public Service/Foreign Affairs, including an evaluation of the Belgian approach to fragility in 5 partner countries in Sub-Sahara Africa and engaging in a policy dialogue related to Mali. Houssynatiy Sy is currently implementting a policy support study of the health risks at the human, animal and environmental interface in Bamako on a request from the Belgian Ambassy in Mali and DGD.