Recognising agents in health systems ….

and complexity

ICHS 5

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Introduction to Complex Health Systems

Recognising agents in health systems ….

and complexity

• Who are they?• What influences their behaviour?• What power do agents have? • What implications for system

functioning?

Going back to the people & software of health systems

Who are the system agents?

Categories of people & organisations

• Patients & citizens• Health providers &

managers at various levels, & other health ‘organisations’

• Public, NGO, & private-for profit organisations

• Various levels/groups/units in ‘collective mediator’

• Other sectors• Professional

associations• Trade Unions• Research groups

• Who else??

In public service organisations, who ...

• controls resources?• has political influence (including media,

pressure groups)?• has involvement in the service delivery

process?• has impact on wider environment of

organisation (e.g. regulatory bodies, local authorities)?

Agents in Systems

May play several system roles,• have relationships with other individuals• be part of groups, and/or work within

organisations, with their own histories of experience – which are part of bigger systems e.g. the

District Health System• be located in specific ‘settings’, with their

own histories

What influences agents’ behaviour?

1. Mindsets, assumptions, beliefs

How many fs?

two of the most powerful and effective of all human fears are the

fear of failure and the fear of success

http://www.theinvisiblegorilla.com/videos.html

Use ‘the Monkey business illusion’

Observable data and experiences

I select data from what I observe

I adopt beliefs, draw a map

I make assumptions based on these meanings

I add cultural and personal meanings

Reflexive loop our beliefs influence our selection

I take actions based on my beliefsThe Ladder of Inference

Conclusion: opinion

reached

Interpretation: meanings &

assumptions added

Selected data:

what you choose

Observable data:

what people actually said

and did

Setting

Institutions

Interpersonal relations

Individual capacities

Observation

Pawson, 2006Personal experience

Views of others

Accepted ways of doing things

Communication processes

Layers of setting: Society,

Organisation

Context as filter

Organisational influencesVisible: the formal organisation

Vision, Mission, Structure, Job descriptions, Goals, Strategies, Operating policies

complicated

Invisible: the informal organisation

Power and influence patterns\Group dynamicsImpulsivenessFeelingsInterpersonal relationsOrganisational cultureIndividual needs

complex

Adapted from Kusek et al.

2013

Personal & cultural meanings

• Discuss examples from papers

Sensemaking

‘the process individuals undertake as they try to understand what is going on around them, as they try to make sense of events and experiences’

(Balogun 2003)

2. Interests

Interests

• Thing for/about which one has concerne.g. power or status or financial gain, fear of

loss• Interests shaped by:

– personal values & factors– memories of similar policy experiences– group loyalty– organisational factors– socio-political, socio-economic factors

• Influence responses to change

Reflection point

• What is your primary position in the health system?

• In that position, what are your interests?– Personally and/or Professionally

3. What power do agents have?

Reflection point

• What is your primary position in the health system?

• In that position, what is your power?– To do what?– Over whom?

• What impact does the exercise of your power have on others around you?

Power in HS: the view from the bottom

National & Provincial Programme & Support Managers

Front Line Manager & Provider

multiple & sometimes conflicting TOP-DOWN demands

Mid- Level Managers

hierarchy

Local Government and Health Consortium, 2004

Politicians

Power in health systems

From top to bottom

From bottom to top

Discretionary power in organisations exists

‘whenever the effective limits on [the public officer’s] power leave him free to make a choice among possible courses of action and inaction’ (Davis 1969, p.4).

Everyday discretionary power

Overt:• Issuing instructions

to others• Publicly refusing to

follow instructions• Being rude to

patients

Covert:• Taking unnecessary

sick days• Taking

unnecessarily long tea breaks

Forms of power

Over others

‘Involves taking it from someone else, and then, using it to dominate and prevent others from

gaining it’

To act “the unique potential of every person and social group to shape their life and world and create

more equitable relations and structures of power”

With others

“finding common ground among different interests and building collective strength

Within “people’s sense of self-worth, values and self-knowledge, central to individual and group

understanding of being citizens with rights and responsibilities”

Sources of power

Personal Organisational

Context:Personal, Group, Organisational, Societal

Implications for systems functioning?

Agents influence system change

The Dynamic Responses Model

Health worker

dynamic responses

De-jure system

De-facto system

Formal health system

Health system as experienced

by patients

Ssengooba et al. 2007

The software matters, in interaction with hardware

Hardware:

Tangible software:

Intangible software:capabilities to commit and engage; adapt & self-renew; balance diversity and coherence

Organ-isational hierarchy

HR estab-

lishment

Technology

Finance

Management knowledge

and skills

Formal management

processesValues &norms

Informal rules

Relation-ships

Comm-unicatio

n

Adapted from Aragon, 2010

Pathways of change are unpredictable

Health system

Intervention

Virtuous or Vicious feeedback loops?

SUPERVISOR PROVIDERS PATIENTS

Acceptability & Trust

Abusive patient-provider

interactions

Example: South African rural allowance

(Ditlopo et al, 2011)Rural allowance introduced 2004, payments awarded retrospectively to July 2003, intended to support rural HR motivation & retention• Impacts?

– Some positive impacts on recruitment BUT– Junior nurses felt undervalued and dissatisfied– Impact of financial incentives short-lived &

inadequate by selvesWhy?

Low relative to total salary & remoteness not considered; perceived as divisive & not poorly

communicated

Change in complex systems

• Change is emergent within organisations – influenced by context; unpredictable, dynamic, non-linear; with unintended consequences that can reinforce or counteract change interventions (Balogun 2006)

Wrap up: All system agents

• Have power to take decisions that influence change in system – are not just robots; have minds of their own!

• Operate within contexts that – influence their mindsets – shape their interests & power relative to

others

• So, organisational change is emergent & unpredictable

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Introduction to Complex Health Systems, Presentation 5. Copyright CHEPSAA (Consortium for Health Policy & Systems Analysis in Africa) 2014, www.hpsa-africa.org www.slideshare.net/hpsa_africa

This document is an output from a project funded by the European Commission (EC) FP7-Africa (Grant no. 265482). The views expressed are not necessarily those of the EC.

The CHEPSAA partners

University of Dar Es SalaamInstitute of Development Studies

University of the WitwatersrandCentre for Health Policy

University of GhanaSchool of Public Health, Department of Health Policy, Planning and Management

University of LeedsNuffield Centre for International Health and Development

University of Nigeria Enugu Health Policy Research Group & the Department of Health Administration and Management

London School of Hygiene and Tropical MedicineHealth Economics and Systems Analysis Group, Depart of Global Health & Dev.

Great Lakes University of KisumuTropical Institute of Community Health and Development

Karolinska InstitutetHealth Systems and Policy Group, Department of Public Health Sciences

University of Cape TownHealth Policy and Systems Programme, Health Economics Unit

Swiss Tropical and Public Health InstituteHealth Systems Research Group

University of the Western CapeSchool of Public Health