Understanding the Pathways for Scaling Up Health Services through CASs

Findings from: Paina & Peters (2012). Understanding pathways for scaling up health services through the lens of complex adaptive systems

Efforts to scale up health services have gained urgency in pursuit of global health goals like the Millennium Development Goals (MDGs). Despite increased funding to support scaling up in low- and middle-income countries (LMICs), many developing nations remain off-track to meet these targets. The scaling-up strategies typically employed have taken a linear and predictable approach, which assumes that duplicating the implementation arrangements, costs, and impacts observed in small-scale, controlled conditions will yield the same results when applied broadly. This approach has led to the creation of standardised models for projecting human resource needs and global costs for scaling up health interventions.

While these benchmarks play a crucial role in global policy discussions and high-level commitments, they often fail to remain relevant when implemented in real-world contexts. Diverse social, political, and cultural environments influence the effectiveness of these interventions. Additionally, in non-research settings, patient behaviours and local contexts introduce significant variability in how programmes are executed. Research highlights that the pathways or processes used to scale up interventions are as critical to their success as the interventions themselves.

Paina & Peters (2012) suggest applying concepts from Complex Adaptive Systems (CAS) to inform the scaling-up process.

Health Systems as Complex Adaptive Systems

Viewing health systems as CAS provides a framework for understanding the dynamic behaviours of interconnected agents and processes from a systems-thinking perspective. CASs are characterised by their ability to self-organise, adapt, and learn from experience, often exhibiting non-linear and unpredictable behaviours. Attempts to control or direct such systems often yield limited responses, and sudden changes may occur when tipping points are reached. For example, expensive health investments may produce little measurable change in health behaviours, whereas societal shifts in attitudes towards smoking bans or contraception can happen unexpectedly.

Health systems in developing nations exhibit many CAS characteristics. They are composed of diverse actors - healthcare providers, policy-makers, patients, regulators, and others - operating at multiple levels across a wide range of services and functions. This complexity makes standardised scaling-up approaches insufficient.

Scaling up health services requires more than expanding coverage. It is a multifaceted process that strengthens delivery organisations, diversifies funding and management systems, and builds a system’s overall capacity to integrate or expand services sustainably. This involves addressing all key building blocks of a health system, including workforce, financing, service delivery, and governance. Importantly, the pathways for scaling up health services vary significantly depending on the context in which they are applied, further underscoring the need for adaptive and context-sensitive strategies.

By leveraging the principles of CAS, scaling-up efforts can move beyond rigid, one-size-fits-all approaches, embracing the complexity and variability inherent in health systems to achieve sustainable and meaningful health outcomes.

Reference:

Paina, L., & Peters, D. H. (2012). Understanding pathways for scaling up health services through the lens of complex adaptive systems. Health policy and planning, 27(5), 365-373.