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Where have all the taxis gone? Complex Adaptive Systems in Action in Beijing

A Beijing taxi driver zooms past. From Flickr/borisvanhoytema


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!


The 2nd Symposium on HSR: As daunting as Kabul?

A view of Kabul as we take off on our way to Beijing


I’ve just arrived in Beijing, China, after a long journey from Kabul, Afghanistan. To say it’s a change of pace is an understatement. The sheer scale of the city is impressive – if a bit daunting – as is the 2nd Global Symposium on Health Systems Research, which I’m here for. I hear there are more than 1,850 participants, which sounds like a lot to me, but is but a mere drop in the ocean of Beijing.

Back in Afghanistan, the team I coordinate works in partnership with the Community Based Health Care (CBHC) unit of the Afghan Ministry of Public Health (MoPH) on a project to pilot community scorecards as a community engagement strategy for improving utilization and coverage of health care. Initial findings from the research we are conducting are inspiring to the team and our Principle Investigator, Dr Anbrasi Edward, and we are looking towards the scale up of the community scorecard under the auspices of the CBHC with a good amount of optimism.

At the symposium, I will be presenting a poster detailing our initial stakeholder analysis as well as touching on highlights from the implementation of the community scorecard. Dr Arwal, the director of the CBHC department (who I have travelled with to Beijing) will be one of three panelists on the MSH convened panel “Getting to Universal Health Care in Fragile States: How Community Health Workers Contribute to Stronger Health Systems”. Dr Arwal will give an overview of the CBHC and the work our two bodies are doing together in Afghanistan.

The poster session will be a first for me, though I’m lucky to have practiced such an activity in one of my epidemiology classes at the Johns Hopkins Bloomberg School of Public Health. The poster presentation was the relatively easy practical element of the aforementioned epidemiology class, which just goes to reinforce a conclusion I came to a long time ago: the tougher classes are the ones that equip students best for work outside the classroom!

One of the main objectives of education is to train minds to enable them to operate at the frontiers of knowledge. Much of the work I am involved in in Afghanistan is, I believe, at the frontier of knowledge – the adaptation of the balanced scorecard to a nation’s health system and the use of the community scorecard, adapted to suit a post conflict setting – and I am excited to share our experiences and findings in the poster session and in informal sessions at the symposium.

I am also excited about the opportunity the symposium presents for learning from other health systems researchers all over the globe. I will be keeping an eye out for the panels, presentations and poster sessions that detail innovations. This symposium holds the potential to unmask research findings, as well as encourage further research, that will be the mainstay of health systems of the future.


Forgetting John Snow at the Beijing HSR Symposium

John Snow's mapping of the Broad Street Pump cholera outbreak


We all know the story of John Snow and the Broad Street pump.  During the 1854 cholera epidemic in London Dr. Snow painstakingly produced a map of the cases and determined that the infamous pump was the origin of the outbreak.  He used his evidence to persuade city officials and the pump handle was removed terminating the epidemic.

Now consider the counterfactual.  Suppose the good doctor had taken an online course on global health systems a few months before the outbreak.  Dr. Snow’s data would have been an excel spreadsheet repeatedly forwarded until it reached the desk of a global disease burden specialist.  Disibility Adjusted Life Years (DALYs) lost would be calculated.  Tree diagrams would be produced.  The incremental cost-effectiveness ratio of various strategies would be tabulated.  With luck, the evidence would be sufficient to host a global summit at which donors would pledge millions to launch a “Decade of Action” against cholera.  With much fanfare a fleet of carriages emblazoned with “The Cholera Project” and a highly vetted logo would be parked next to project headquarters ready to avert cholera DALYS across the globe.  No doubt there would be a research institute to develop biomedical solutions — an amazing vaccine, or special rehydration liquid that would require an army of doctors, nurses, and health workers to aid the stricken.  John Snow would be promoted to head the corps of do-gooders, and his picture would be featured prominently in The Lancet as a global health hero.

Nightmare over.  History did not turn out that way—at least not for 19th century England.  Fortunately due to an enlightenment era faith in the responsibility and capacity of local government to improve the wellbeing of humanity, the people of England institutionalized the local solution of local public health problems. Despite tremendous economic growth in the 19th century, health in the UK did not improve until the English invented public health.  More money was not enough to improve health and life expectancy did not top 40 years until 1870. Throughout the 1840s, 50s, and 60s England passed a series of laws that created local health boards, empowered local health officers, and developed local health codes that could be locally enforced.  Political resistance to health reforms occurred locally and was overcome locally.  Public health reforms prevailed with much more success after voting reforms in 1867 enfranchised the working men whose families stood to gain the most from transforming pestilent crowded slums into livable cities.  The John Snow strategy worked and England’s life expectancy began to climb from 40 years in 1867 to 65 by 1945 — before antibiotics and most modern 'cures' were discovered.  Other countries around the world had the same success with the same strategy.  Prior to the 1950s, economic growth alone wouldn’t bump a country’s health statistics; doctors and universal coverage offered weak remedies.  Public health strategies helped translate growing prosperity into hygienic living conditions and this was the route to good health.  It still is.

This week the world will gather at the 2nd Global Symposium on Health Systems Research in Beijing meeting to collectively forget everything that John Snow stood for. Almost all the programming is about improving the delivery and financing of medical services. Attendees will forget that the best solutions are local solutions based on local data used by local health advocates in harmony with their local community.  Few presenters seem to notice that the best and most important part of any health system is not the gleaming hospitals and ICUs.  The part that of the health system that creates health changes the social and physical determinants of health through good old fashioned public health practice.  Most participants are content to sway to the siren’s song of universal coverage and pretend that doctors are the solution to every malady.

James Joyce speaks in Ulysses of the “ineluctable modality of the visible” – what can be seen with the eye becomes the mode and draws our mind with no escape.  The unseen forces in the world may be much more powerful than the visible, but even the most well-intentioned and wise will be drawn to what they can see.  The whole world sees doctors and nurses so deploying them and fixing their business problems has become the business of global health.  Public health officers stay out of sight by preventing problems before they occur. Who has ever seen a public health officer?  What Broad Street survivor would recognize or remember that their life was saved by John Snow?

The good news is that at least one woman in Beijing remembers John Snow. Dr. Afisah Zakariah is Director of Policy, Planning, Monitoring, and Evaluation for the Ministry of Health in Ghana.  At the Thursday session of the conference she described Ghana’s plans to strengthen its essential public health functions.  Building on a World Bank measurement tool, Ghana will audit the performance of district health management teams.  The audits will give each district health official a same-day report card and form a foundation for a personalized performance improvement plan with regular follow up coaching visits.  The essential public health functions that will be graded and improved in Ghana are the essence of what John Snow did on Broad Street — collecting and using local surveillance data, mobilizing the community around the data, and collaboratively implementing local public health measures.  Lucky for Ghana that Dr. Zakariah is on board.  This is potentially lucky for Dr. Zakariah’s audience.  Maybe they won’t forget John Snow and the spirit of 1854.


Health Systems Global – why care????


As colleagues from around the world converge on Beijing, I am stuck in Washington, D.C. with the flight departure screens displaying a never-ending list of cancelled flights. Here in D.C. not many people are aware of the symposium in Beijing, and not many people care about Health Systems Global – or as I would prefer it  to be called, the new Society for Health Systems Research. I am reminded of an email written by a friend when I wrote suggesting that he stand to be a Board member – he wrote back, saying (and I paraphrase): “Why should I care about this, I don’t think this  new global society will have much impact on my country, or the things that I care about.” From a wind and rain-swept, election-obsessed D.C., it is easy to feel the same.

But I do care, and I am upset that I will not be there for the opening of the Symposium. Why is this?

I have been blessed to have worked with some fantastic researchers in this field – too many to name them all here – but despite this, it has been rare that I have felt part of a professional community. I have constantly had to think about how I position my specific interests in health systems research in a way that will make sense to my epidemiological/ economist/ policy-oriented [delete as appropriate] colleagues. At the first symposium in Montreux I was struck by the fact that, for the first time ever, 80% of my professional network was present at the same meeting.

Cynics might say, ‘So what, this is just another opportunity for an expensive jamboree, that everyone enjoys but achieves little in the end’. I beg to differ.

No one came to HSR to get rich, or to have their name plastered all over the Lancet (pah, the Lancet only recently figured out how much HSR matters). We came because we were intrigued by the dilemmas, because we saw the potential to change health systems, and we began to get an inkling of the major impacts that such changes could have on the poor – not just on their access to services, but on how their voice is included in policy debates, and how their needs are reflected across government.

Health systems research has been an orphan subject for way too long – squeezed between prestigious, epidemiological randomized control trials on the one hand, and mainstream social science research on the other. The Symposium and the new global society for health systems research can be the first steps in changing this and thus, changing the way health systems work for the poor and disenfranchised, as well as the middle class. And that’s why I’m standing for election to the Board of the Society.

For the Society to really work, we need everyone engaged – all those who have been laboring in the HSR trenches and who currently think that there is nothing in Beijing, nor the Society, for them. Despite IHP’s best (and sometimes extremely entertaining efforts), many of us are still in the dark as to what the Society is about. That needs to change: with transparent and responsive governance, the Society could help build community, build HSR capacity, develop a common language and terminology for HSR, and help enable us all to be the change agents in health systems that we want to be.

Airports in D.C. re-open tomorrow: I will be in-line early. Wish me luck!


Emerging Voices 2012: Moses’ experiences 

Moses gives his presentation at the final conference


The 2nd Global Symposium on Health Systems Research officially kicks off today here in Beijing, but I’ve already been here for nearly two weeks participating in the Emerging Voices program. Emerging Voices is a joint venture by the Institute of Tropical Medicine in Antwerp and Peking University School of Public Health designed to build presentation skills and strengthen voices of younger health systems researchers. The program was incredibly diverse, featuring courses on issues related to health systems research and skills-building workshops on scientific presentation and scientific writing in English in addition to cultural activities in China.

I was selected to participate in the venture as a young researcher from Makerere University School of Public Health in Uganda. I am a part of the wider FHS team in Uganda, where I focus on maternal and neonatal health in low-income settings like Uganda. Now that the venture is over, there are three main reflections I have on the two-week session.

The first part of the training program involved an introduction to new methods of presenting scientific research findings to a diverse audience in an effective way. Two particular methods were introduced: Pecha Kucha and the Prezi. Both of these mechanisms have at their core the use of illustrative pictures to communicate. Pecha Kucha emphasizes brevity, with twenty slides of images each rotating automatically after twenty seconds to force the presentation forward. Prezi is an online system for creating dynamic and creative presentations. I found these approaches very creative as it differed from the convectional PowerPoint presentation principals, which mostly have text. The other advantage of the picture principle is that it gives the presenter the opportunity make the presentation in amore natural and interesting way, therefore capturing the attention of the audience.

Secondly, we had cultural and field visits in which we were treated to different local Chinese traditional sites and introduced to the Chinese health system.  I particularly found the cultural visits very rich and was delighted to be able to touch base with old Chinese traditions, which are very vividly painted at the Great Wall, the Summer Palace and the Forbidden City.  I was also more than delighted to have a chance of seeing a panda at the Beijing Zoo. But more importantly, during the field visits, I was part of a group that went to what is called the ‘rural parts of Beijing’. Here we visited the district health office and two of their health centers. I was particularly impressed by the integration of Chinese traditional medicine with the western medicine within the mainstream health system. This means that they give both disciplines and approaches adequate resources and attention in terms of developing them further.

And lastly, Emerging Voices offered me an important chance to meet and receive some career guidance from senior health systems researchers. We had a huge number of senior researchers and I was able to meet some experts in participatory action research methodologies. This was of interest to me because it forms the principals upon which we are building our current FHS intervention – MANIFEST. MANIFEST is the maternal and neonatal implementation for equitable systems. Our overarching goal is to reduce maternal and neonatal mortality through tapping into exiting community resources and working through exiting structures in order to increases chances of continuity. I believe that Emerging Voices has introduced me to a network of researchers in my field and therefore opened possibilities for learning and sharing. I therefore want to sincerely thank the organizers of the emerging voices first for the organization and for partially funding my training. I would also want to thank the Future Health Team in Uganda for supporting my travel to Beijing to attend this training.

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