BY LIGIA PAINA, PhD CANDIDATE, JOHNS HOPKINS BLOOMBERG SCHOOL OF PUBLIC HEALTH
I was cold, and I was wet – having waited for a taxi home for about an hour. And despite my interest in the subject, I somehow took little solace in the fact that getting soaked was the failure of a complex adaptive system. After the closing plenary of the 2nd Global Symposium on Health Systems Research in Beijing, the skies opened up. And as the afternoon progressed to evening, the rain turned to sleet, and eventually even snow. Many people were heading to the airport to head home after the conference, and yet they couldn’t get a taxi. I was lucky that I wasn’t in a rush to get to the airport, but I was among the wandering masses, traipsing through the streets against the rain and wind trying to get back to my hotel, bemused that taxis were in such short supply when demand was clearly at its highest.
At one level, in a city of more than 20 million people, it’s easy to imagine that if suddenly a million plus people no longer desire to walk from point A to point B, that the traffic system must absorb a sudden tide of passengers. In this case, the metro continued, and the busses were running smoothly, and they likely bore the brunt of the increased traffic. Taxis, on the other hand, were particularly scarce.
Later, someone explained to me (and this is second-hand knowledge, I haven’t checked Beijing city policy so please correct me if I’m wrong!) that in order to keep Beijing taxi drivers in check, they made the drivers themselves directly responsible for the costs associated with an accident. That may help keep speeding and reckless driving to a minimum when the skys are blue(ish -- it is Beijing after all), but when it comes to driving in more difficult road conditions, when demand is at its peak, in means that taxi drivers make something of a different economic calculation and stay off the roads. Talk about unintended consequences.
But the local transport system was not the only complex adaptive system (CAS) on show here in Beijing. As a PhD student who is currently grappling with understanding Uganda’s complex health workforce dynamics for my dissertation research, I was unsure what to expect to hear about complex adaptive systems (CAS) at the 2nd Global Symposium on HSR. I was fortunate to have participated in the 1st Global Symposium on HSR in Montreux in 2010, which included a handful of discussions on this topic. In Montreux, the discourse was focused on conceptualizing CAS and systems thinking, asking what it they are and why should we apply them in health systems research.
The discourse in Beijing this week has been quite different. Yes, there are still questions on CAS terminology, theoretical underpinnings, and, to some extent, the rationale of using CAS in health systems research. But there is a noticeable shift towards building the evidence, refining and adapting methods and tools to study health systems through a CAS lens, and moving from theory to practice.
For example, David Peters chaired a session on the last day of the conference where colleagues from Uganda, China, JHSPH, and IDS presented their work on CAS – ranging from country-level research on CAS, to reviews of the non-health literature, and to computer simulations. The launch of the recent Health Policy and Planning supplement on Systems Thinking highlights additional interesting case studies and reviews, including an analysis of FHS projects in Bangladesh, Uganda, and China through the lens of the Develop-Distort Dilemma. Applications of methods such as social network analysis to policy and health systems networks have also been presented. Several poster presentations (including my own presenting preliminary findings on local system adaptations in the management of dual practice in Uganda) also focused on using a CAS lens to explore and evaluate health systems issues.
In addition to learning about all of these applications, it has also been interesting to link up with other researchers applying CAS methods and tools in their work, such as those whose proposals have been selected to be developed within the context of the Alliance for HSPR’s next supplement on applications of CAS, professors and students using CAS in their work, and other interested colleagues from both research and non-research organizations.
CAS in health systems research is still abstract. Indeed, the applications of qualitative and quantitative methods to this topic are complicated and communicating the methods and results to research users and policy-makers (and even other researchers!) remains challenging. Nevertheless, it is an exciting time to work in this field as we are bringing in multiple disciplines and perspectives to examine the “why” and “how” in the rich and complex contexts within which we are working.
Confucius once said that “the cautious seldom err.” In the context of working on CAS, the journey forward might be somewhat risky – as researchers are trying to develop and disseminate their work. However, with a healthy dose of skepticism and a collaborative, multidisciplinary approach, the journey ahead will also be exciting and fun!