Understanding pathways for scaling up health services through the lens of complex adaptive systems
Abstract
Despite increased prominence and funding of global health initiatives, efforts to scale up health services in developing countries are falling short of the expectations of the Millennium Development Goals. Arguing that the dominant assumptions for scaling up are inadequate, we propose that interpreting change in health systems through the lens of complex adaptive systems (CAS) provides better models of pathways for scaling up. Based on an understanding of CAS behaviours, we describe how phenomena such as path dependence, feedback loops, scale-free networks, emergent behaviour and phase transitions can uncover relevant lessons for the design and implementation of health policy and programmes in the context of scaling up health services. The implications include paying more attention to local context, incentives and institutions, as well as anticipating certain types of unintended consequences that can undermine scaling up efforts, and developing and implementing programmes that engage key actors through transparent use of data for ongoing problem-solving and adaptation. We propose that future efforts to scale up should adapt and apply the models and methodologies which have been used in other fields that study CAS, yet are underused in public health. This can help policy makers, planners, implementers and researchers to explore different and innovative approaches for reaching populations in need with effective, equitable and efficient health services. The old assumptions have led to disappointed expectations about how to scale up health services, and offer little insight on how to scale up effective interventions in the future. The alternative perspectives offered by CAS may better reflect the complex and changing nature of health systems, and create new opportunities for understanding and scaling up health services.
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Little is known about scaling-up initiatives in Indigenous contexts with diverse traditions, governance structures and relationships that influence readiness and capacity for community food actions.
“Little is known about scaling-up initiatives in Indigenous contexts with diverse traditions, governance structures and relationships that influence readiness and capacity for community food actions [23, 24].”
There are multiple implementation strategies that, in specific circumstances, can effectively address different barriers to implementation, as well as the same barrier.
“That is, there are multiple implementation strategies that, in specific circumstances can effectively address different barriers to implementation, as well as the same barrier (e.g., financing) [83–85].”
From “Scaling-out” evidence-based interventions to new populations or new health care delivery systems (2017) · cites this paper as [84]
Simple rules offer a means of understanding the emergent behaviour of healthcare organisations, professionals and patients.
“These offer a means of understanding the emergent behaviour of healthcare organisations, professionals and patients [76–79].”
From Implementation, context and complexity (2016) · cites this paper as [76]
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“Little is known about scaling-up initiatives in Indigenous contexts with diverse traditions, governance structures and relationships that influence readiness and capacity for community food actions [23, 24].”
Background
- Authors
- Paina, L., & Peters, D. H.
- Affiliations
- Johns Hopkins University (US)
- Corresponding author
- Peters, D. H.
- Venue
- Health Policy and Planning
- Publisher
- Oxford University Press (OUP)
- Published
- 2011-08-05
- Volume
- 27
- Issue
- 5
- Pages
- 365-373
- ISSN
- 0268-1080 (ISSN-L)
- 1460-2237
- OpenAlex
- W2143926494
- Cited by
- 534
- References
- 74
- Citations by year
- 2026: 35 · 2025: 28 · 2024: 33 · 2023: 32 · 2022: 39 · 2021: 66 · 2020: 43 · 2019: 39 · 2018: 41 · 2017: 42 · 2016: 34 · 2015: 33 · 2014: 29 · 2013: 16 · 2012: 23
- FWCI
- 40.67
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Health Policy and Planning (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Health Sciences › Health Professions › General Health Professions › Healthcare Systems and Practices
- Social Sciences › Economics, Econometrics and Finance › Finance › Healthcare Systems and Reforms
- Keywords
- scaling up health services, complex adaptive systems, health systems change, path dependence, feedback loops, scale-free networks, emergent behavior, phase transitions, health policy design, Millennium Development Goals, unintended consequences, local context, data-driven problem solving
- MeSH terms
- Delivery of Health Care, Developing Countries, Health Plan Implementation, Health Planning, Health Services Needs and Demand, Organizational Objectives, Systems Theory, United Nations, Global Health
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