EvangelosErgen_ComplexityInHealthcare_Dissertation

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UNIT NUMBER EMBA
UNIT TITLE Dissertation (Supervisor Dr Alexandros Psychogios)
SEMESTER Spring13 SESSION 2012‐13
COURSEWORK NUMBER SUBMISSION DATE DUE 30/04/2013
COURSEWORK TITLE Understanding Healthcare Service in a Complexity Context.
Lessons from the turbulent Greek Healthcare Sector.

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Evangelos ERGEN

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Master of Business Administration
DISSERTATION
with subject:
Understanding Healthcare Service in a Complexity Context.
Lessons from the turbulent Greek Healthcare Sector.
by
Evangelos ERGEN (EX10130)
Supervisor: Dr Alexandros Psychogios
Thessaloniki – 30 April 2013

List of Abbreviations, Acronyms and Words
CIA Central Intelligence Agency of USA
CAS Complex Adaptive System
EC European Commission
ECB European Central Bank
EEC European Economic Community
EMU European Monetary Union
EOPYY The National Greek Public Insurance Health Organisation
EU European Union
GDP Gross Domestic Product
Grexit
A popular word used to characterize the possible exit of
Greece from Eurozone
IMF International Monetary Fund
Group Group of Members States of Eurozone
OECD Organization for Economic Cooperation & Development
Troika
European Commission, European Central Bank,
International Monetary Fund
USA United States of America

List of Tables and Figures in the study
Figure 1. The Research Objectives of the study Page…..5
Figure 2. The Research Questions’ Framework of the study Page…..6
Figure 3. The IPAT Model Page…..8
Figure 4. The Factors of stability mix Page…..9
Figure 5. Characteristics of Complex Adaptive Systems Page…..11
Figure 6. Healthcare services (agents’ links) Page…..14
Figure 7.
Eco-map of the pharmaceutical provision system - public
spending (old system)
Page…..20
Figure 8.
Eco-map of the pharmaceutical provision system -public
spending (reformed system)
Page…..21
Figure 9. Practicing Complexity (Perpetuity) Page…..22
Figure 10. Conceptualising the Complexity Space (in healthcare) Page…..23
Figure 11. The 7 Impact Variables when navigating in healthcare sector Page…..24
Figure 12. The 5 steps for Co-evolving with Complexity Page…..24
Figure 13.
The phases of adaptive cycle (through resilience and capital
accumulation)
Page…..25
Figure 14.
The 4 Generic Types of Dynamic Behaviour
In Complex Adaptive Systems
Page…..26
Figure 15. The processes for developing mindfulness Page…..27
Figure 16. Putting Complexity to Work (strategic components) Page.....28
Figure 17.
The structure of the National Healthcare System (NHS) in
UK
Page…..40
Figure 18. The Context of Healthcare Page….41
Table 1. Sampling categories Page.....31
Table 2. The Groups in Greek healthcare system Page…..34
Table 3. The most powerful groups in Greek healthcare system Page…..35

TABLE OF CONTENTS
Abstract
1. Introduction page………... 2
2. Problem Statement (the study’s rationale) page………... 3
2.1 The Greek Healthcare Sector page………... 3
2.2 The Greek Crisis page………... 3
3. Aims and Objectives page………... 5
3.1 The overall aim page………... 5
3.2 The research objectives page………... 5
3.3 The research questions page………... 5
3.4 Overview of the study (the structure) page………... 6
4. Literature Review page………... 7
4.1 The structure of Literature Review page………... 7
4.2 Complexity page………... 7
4.2.1 Growth & De-growth within Complexity 7
4.2.2 The relation with Health & Healthcare Governance 8
4.2.3 The search for equilibrium 9
4.2.4 Complexity & Complex Adaptive Systems (CASs) 10
4.2.5 Characteristics of Complex Adaptive Systems 11
4.3 Healthcare & Complexity page………... 14
4.3.1 The Complex Characteristics of Healthcare 14
4.4 The case of Greece page………... 16
4.4.1 Historical economic data 16
4.4.2 Recent economic situation 17
4.4.3 Consequences 18
4.4.4 Healthcare 19
4.5 Demystifying Complexity page………... 22
4.5.1 Using Complexity in Practice 22
4.5.2 Identify the Complexity Space 22
4.5.3 Navigating in the Complexity Space 23
4.5.4 Putting Complexity to Work 25
4.6 Conclusions & Link with the study page………... 28
5. Methodology page………... 30
5.1 Introduction page………... 30
5.2 Approach page………... 30
5.3 Data Collection page………... 30
5.4 Sampling page………... 31
5.5 Data Analysis page………... 31

6. Ethics& Ethical Issues page………... 33
7. Findings & Discussion page………... 34
7.1 Information Asymmetry page………... 34
7.2 Relations & Interdependencies page………... 36
7.3 Heterogeneity & Diversity page………... 37
7.4 Attractor & Attractor Patterns page………... 37
7.5 Generative Relationships & Patterns of Behaviour page………... 38
7.6 Collective Reflexivity page………... 39
7.7 Elements from NHS (The National Healthcare System of UK) page………... 39
8. Conclusions of the study page………... 42
8.1 Discussion on Literature Review page………... 42
8.2 Implications page………... 44
8.3 Limitations page………... 44
8.4 Further Research page………... 44
8.5 Contribution of the study page………... 45
References page………... 46
Appendices
Appendix A: GREECE: GDP in the decade 1951-1961 (growth rates)
Comparison with other OECD countries page………... 53
Appendix B: GREECE: GDP in the decade 1951-1961
Distribution of growth rates per sectorries page………... 54
Appendix C: GREECE: Unemployment 1970-1993 page………... 55
Appendix D: GREECE: Directives in controlling pharmaceutical
spending (structural fiscal reforms in Greece) page………... 56
Appendix E: GREECE: Directives in adopting the use of generic
medicines (structural fiscal reforms in Greece) page………... 57
Appendix F: GREECE: Directives in pricing of medicines
(structural fiscal reforms in Greece) page………... 59
Appendix G: GREECE: Directives on prescribing and monitoring
(structural fiscal reforms in Greece) page………... 60
Appendix H: Mapping the process of organizational learning
from crisis page………... 62
Appendix I.1: Semi-structured interview questionnaire
open-ended questions (original questionnaire) page………... 63
(questionnaire in Greek language) page………... 65
(the playing cards interactive version) page………... 67

Appendix J: The study at a glance
Structural mind-map of literature review
& main thoughts and findings page………... 73
(this appendix is better seen in plotter printing format)
Appendix K: Characteristics of Complex Adaptive Systems page………... 74
Appendix L: Characteristics of Complex Adaptive Systems
in Healthcare page………... 75
Appendix M: Data registration
(translated raw data) page………... 76
Appendix N: Data categorization (taxonomy)
(according to research questions’ framework page………... 77

ACKNOWLEDGEMENTS
First of all, I would like to express my gratitude to the Administration Board of the International
Faculty of the University. Without their grant for scholarship in the MBA course, I would not be able
to attend it. For this reason, I have tried to reach a high level of performance during my studies as a
minimum proof to their decision and generosity.
Second, I would like to thank Dr Leslie Szamosi, the Academic Director of the course. He is one of
the few personalities from whom you can learn more in less time. He gave me the first triggers for
the present study, in a short discussion we had almost two years ago.
Third, I would like to thank my supervisor, Dr Alexandros Psychogios, who provided me with the
necessary guidelines in order to transform my thoughts and findings in an academic paper of high
standards.
Last, I deeply thank Ms Savvato Karavasiliadou, PhD Candidate and RN Nurse at AHEPA
Hospital of Thessaloniki. Without her help I would not be able to perform my research and get the
interview questionnaires. She was a valuable participant of this study who also gave me very
important information about the Greek healthcare sector. I wish her every success in her future
endeavors.
Thessaloniki, 30 April 2013
Evangelos Ergen

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Understanding Healthcare Service in a
Complexity Context. Lessons from the
turbulent Greek Healthcare Sector.
Evangelos Ergen, ergen@ergen.gr Issue Date: 30 April 2013
http://www.ergen.gr
http://www.evangelosergen.eu Supervisor: Dr Alexandros Psychogios
Abstract: Healthcare systems demonstrate characteristics of complex adaptive systems.
Moreover, they acquire attributes that could not be analysed through traditional managerial
techniques, not even dealt with. This study intends to analyse complexity and complex adaptive
systems (CASs) as an integral component of health governance, especially in times of crisis, when
countries are facing non-linear effects and are obliged to deal with emergence and self-
organisation, as sources of novelty and surprise. Through complexity’s lens, it is easiest to
accommodate diversity and understand the special characteristics of healthcare.
Furthermore, by examining healthcare systems as CASs, this reveals a different mindset to
preview. Here patterns of interaction are recognised as vital components, and participants, are the
agents of the system. Such systems are familiar to emergence, co-evolution and self-organisation
as a resilient practice which results from a robust response to external shocks. Giving the case of
Greece, and healthcare sector’s specialties and distortions, this study suggests picturing the
current situation in a holistic view rather than reductive one. There is no chance to predict and to
control in a complex adaptive system. It is possible though to put complexity into practice while in
parallel apply tactics such as, minimising exposure, acquiring flexibility, doing observation, making
sense of what happens, and developing mindfulness. In addition, improvisation and bricolaging,
could be helpful techniques in dealing with complexity. While globalisation incorporates
unknowability, the study on complexity encompasses remembering and forgetting history, which is
nothing more than the capacity to learn. This study suggests that external shocks is the appropriate
time for the systems to apply changes that were obliged but never had the chance or dared to do.
Within this framework we intend to understand the agent-based nature of the sector, identify the
role of connectedness among healthcare groups and investigate the emergent dynamics. An
exploratory research using qualitative analysis was performed. Semi-structured interview
questionnaire was used as the research instrument. Sampling was convenient and judgmental and
was consisted of 37 respondents, who are professionals from different groups of Greek healthcare
sector.
Findings have revealed that sector is currently in a transitional stage. Outside imposed
restructures, have activated a number of changes towards new self-organisation. The sector from
doctor-centred is pushed to acquire new attributes through the emergence of new dynamics that
are expected to bring forth a new structure. Nevertheless, changes will delay since there are still
contradictions among groups and there is no clear understanding of the new status. Previous
patterns and interdependencies have nurtured a blurred environment. The sector was accustomed
to apply mechanistic approach which finally proved inadequate in the absorbent of signs for
change. As a result, it is now obliged to perform too many changes in short time.
Keywords: health governance, healthcare, complex adaptive systems, complexity, Greek crisis

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1. Introduction
The Greek healthcare sector is a complex adaptive system which demonstrates analogous
characteristics. It is independent and in the same time interdependent with other systems that co-
exist. This is the overall framework of current study through which we intend to approach the
subject.
Dealing with complexity is the opposite of applying the mechanistic view. In times of crisis,
systems leave order and tend to experience chaos and complexity as dynamic behaviours.
Planning and controlling are gradually replaced by patterning and adapting in changing
environments where prediction is impossible. Authority is not necessarily the source power rather
than the emergent players who happen to find themselves in the centre of a whirl. However, self-
organising is the ultimate target for a system to sustain. This may include the sad scenario of
destructing those parts that are considered obstacles for self-preservation or vice versa in case of
destructive innovation (the white-page strategy; Klein, 2011).
However, societies from time to time get into a mechanistic operation, in an effort to stabilise
their prosperity and to exploit their achievements (Goudelis, 1993). Experience has shown that
whenever there is a need for change, focus leaves the mechanistic-Newtonian approach, and
tends to see people as inherently complex human beings. In complex systems any imposition of
demanding measures has direct impact to their living parts, sometimes with uncontrollable
outcomes. Healthcare systems usually are the first impacted in a society under pressure, especially
when there are needs for repositioning.
Greece is experiencing a strong and violent set of pro-cyclical and counter-cyclical economic
conditions which stem from continuous recession. On the other hand, due to certain specialties -
oligopolistic market structure, small market size, and paternalistic mindset - the local economy
demonstrates distortions such as an increased inflation in an aggravated downturn situation. The
bulk of loans that Greece borrowed from external creditors, in combination with the policies for
internal devaluation as imposed through memorandums, have created an explosive mix.
Continuous public deficits and increased expenses of central government have revealed enormous
weaknesses and inability of the country to finance its basic needs.After almost four years of
economic isolation, the country has started to demonstrate signs of social decay. However, within
the turbulence of entropy, the country has a unique opportunity to change its structures rather than
simply change roles among players, rejecting for the first time in its history the “us against them”
mindset (Papadopoulos, 2003). Therefore, this study discusses whether the sector is ready to
perform changes as well as identifies the impact of complexity’s characteristics under current
situation.

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2. Problem statement (the study’s rationale)
2.1 The Greek healthcare sector
Greek healthcare sector, during the last two years, is experiencing a deep restructure aiming:
(a) to decrease the number of hospitals and clinic units in operation, (b) to decrease the working
hours of medical staff, especially the ones appeared as overtimes and (c) to decrease the number
of employees in the sector. An additional general measure is to cut-off budgets regarding the whole
healthcare supply-chain. Such changes are addressed mostly to the public sector which represents
the bigger percentage of healthcare services in the country. Moreover, the imposed healthcare
reforms include the radical decrease of pharmaceutical spending both for in-hospital and out-
hospital cases. The ladder raises a series of perplexed consequences involving pharmaceutical
industries, medical companies as well as any related company that the public system had
cooperation with.
The immediate impact of cut-off policies was the inadequate healthcare service provisioning
with multiple social effects. During 2012, the sector faced an enormous instability and uncertainty
since planned reforms did not bring the desired results. Nevertheless, this was mostly due to social
partners’ opposition. Social groups that had cultivated a certain status quo demonstrated an
increased sense of self-preservation. On the other side, government had postponed payments for
healthcare services and products to private suppliers in an effort to re-negotiate and settle down a
new framework of cooperation. For example, there was promoted the practice of using generic
drugs instead of the branded ones. The aim was to rationalise expenses and apply a paying
scheme which could be affordable according to financial abilities. Such decisions raised different
behaviours among participants in the sector. Some multinational companies left Greek market and
withdrew their products. Pharmacists started a series of strikes trying to push the system. Doctors
are currently in a transitional stage since some of them do strikes while others continue to offer
their services under the new regime. Medical staff mainly in public sector, works in a shrinking
environment. The sector experiences a chaotic condition. Possibly this is the first time that social
partners have to decide, what kind of healthcare they want to provide in the country; a purely
privatised sector, controlled by the markets’ rules, where the health capital could be the object of
trading negotiations; or a balanced sector, following certain governance rules under the respect of
health as a national asset of a country based primarily on reciprocity and solidarity.
In this environment, this study adopting the complexity perspective, tries to approach the sector
as a complex adaptive system and discuss the complex characteristics of the system and how
these affect healthcare service under current pressures.
2.2 The Greek crisis
Greece was always a geopolitical target for many reasons (Stratfor, 2010). The long-historical
and cultural connection with East in contrast to its geographical placement close to the Western
civilisation was always a source of conflict. It was primarily a country-region that belonged to
different empires through time, had accommodated different people, and had absorbed mixed
affections from different cultures. Besides that, although it had faced various challenges the country
-in its different forms- managed to survive through certain practices. One of them, possibly
emerged due to circumstances, was that inhabitants tried to innovate in order to differentiate and
keep track with any changes. As a result, the risen natives developed similar skills through time.
However, for once more the country experiences tough conditions and remains in the centre of
interest as a unique experiment; the case of a country which faces the dilemma of exiting from a
strong monetary consortium in the 21st
century, which may end to isolation and its consequences
or remaining in Eurozone by devaluating its final product.
Although the economic crisis has global characteristics the country lives the consequences
through its own specialties. A number of scientists have tried to discuss and present their findings
on what crisis means and who is responsible for it. Schneider and Kirchgassner (2009) identified
that global community is currently observing one of the most severe and deep world financial and
economic crises in history. They both argued that the origin is USA. Lang and Jagtiani (2010), as
well as Wallison (2010) aligned in the same conclusion. On the other side, Gross and Alcidi (2009)
highlighted that Europe had already internal weaknesses to cover and it was a matter of time for
them to be revealed. In contrast, there were a number of scientists who argued that current crisis
has antecedents in earlier crises, including the “Great Depression” of ‘30s (Gaffney, 2009;
Wheelock, 2010). Nevertheless, a quick glance in the past demonstrates that humanity
experienced economic crises even from the 12th
century, when Europeans established their states.

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Back to Greece, the global situation in combination with internal imbalances and distortions,
directed the country in facing a multilevel economic recession, consisted of the following
characteristics (Provopoulos, Bank of Greece Annual Report, 2010):
• A negative environment (both economic and social) due to: (a) the lasting structural
weaknesses and distortions, (b) the macroeconomic imbalances, and (c) the non-
sustainable development, as proved to be a-posterior, the growth during the years
1996-2007.
• The high risk for the country loosing the opportunity, to get advantage of the global
recovery.
• The luck of confidence in country’s prospects to overcome its problems and return to
development and prosperity.
• The inability to get external financing due to the above characteristics.
The result was for the country to enter in 08 May 2010, officially under the economic supervision
of the troika consisted of: (a) the International Monetary Fund (IMF), (b) the European Central Bank
(ECB), and (c) the European Commission (EC). Practically this was done through a memorandum
of recovery (Memorandum of Understanding of Specific Economic Policy and Conditionality)
accompanied by a trilateral agreement (contract) which provided an enormous loan of 110 billion
euro. It is interesting though, that Greece was represented separately in the agreement by: (a) the
Greek government, and (b) the Bank of Greece.
Since the country could not secure external funds, it was unable to borrow through regular
global financial channels of income. International funds were not willing to purchase Greek state
bonds, requesting interest rates that were over 6% on that time. On the other side, Greece as a
member of Euro zone (European Monetary Union-EMU), requested help from its euro partners who
in response undertook the responsibility to provide help under certain conditions. The
memorandum signed, as the ultimate saving plan, introduced a series of structural reforms that the
country was obliged to perform in a very short time, within three years (until 2013). The government
(Socialist Party with G. Papandreou as Prime Minister and G. Papaconstantinou as Minister of
Economics) under the pressure and the panic of the situation directed the country into custody.
Therefore, after two years of implementation of the First Economic Adjustment Programme
(Memorandum), the results were disappointing and almost catastrophic. The measures and
reforms in the way that these applied or not applied had raised a series of negative consequences
for the country instead of ensuring the opposite. Practice demonstrated that neither of the local
political forces proved to be eligible to undertake the responsibility to perform the reformation plan
not even able to present alternatives. Instead, on 09 February 2012, the country, after a series of
negative evaluations by troika, adopted the Second Economic Adjustment Programme, under a
new, more strict and dangerous for its sovereignty contract. This had duration of three years (till
2015) and was accompanied by an additional 130 billion euro loan. The money was agreed to be
provided in small instalments depending on reviews related to the progress of the programme. The
government applied part of the programme and did not proceed to structural reforms as it should.
Instead, it decided to balance the situation through single fatal practices of decreasing horizontally
wages and pensions in public and private sectors. That was done on the basis of collecting money
and presents some results. Both First and Second Adjustment Programmes included a specific
mindset of restructuring status quo but, this found strong opposition among social partners. It is
very difficult to break links that were rooted for many years.
During 2012, the negative situation turned even worse, especially in terms of experiencing a
kind of death-spiral effects like, increasing unemployment (over 25%) with increasing taxation,
devaluation of labour cost, inflation and zero investments. No prospects were given by any social
partner, while in the same time, predictions for recession for 2013 range 4% to 8%. Furthermore,
current reformative implementations in combination with the imposed practice of internal economic
devaluation which is the backbone of the whole change plan, creates an explosive social mix, with
unexpected reactions. This reformation scheme had already a direct impact, primarily in
devaluating cost of life while keeping the same currency and moving the cutting-cost among others
in health and healthcare.

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3. Aims and Objectives
3.1 The overall aim
The overall aim of the research is to identify and explore the emergence and self organisation
as the major transitional components that stand between death and renewal in complexity. In
practice, this is represented through certain managerial practicalities which, in this case, could be
applied in healthcare sector, in terms of putting complexity to work. Being in the centre of
turbulence, healthcare should sustain while preserve social principles but adopt a modernised
mindset. The intention is definitely not to model any complexity’s manipulation scheme. On the
contrary, it is to investigate and analyse the significance of acting, based on limited knowledge and
ambiguity.
3.2 The research objectives
Figure 1. The Research Objectives of the study
3.3 The research questions
Following the aim and objectives, the study poses a number of questions. The target is to
discuss and suggest managerial practicalities in terms of complexity especially in current situation,
where both healthcare sector and the country experience a shock effect. The research is going to
follow a qualitative analysis since the subject demonstrates increased specialties. Therefore, in the
next Figure 2, is given the concrete questions’ framework to be used as a guide in the survey.

The Research Objectives of the study
1. to understand the agent-based
nature of the healthcare sector;
2. to identify the role of
connectedness among agents;
3. to take into consideration the
emergent dynamics of the sector;
Self-organisation is a characteristic of
complex adaptive systems which could
be considered as the end-result in a
series of changes in behaviour, in
combination with the emergence of
dynamics which establish new forms and
structures. Moreover, this comes as a
result of the system’s decision to acquire
a new status and stabilise its
components after renewal.
In order to realise the overall aim, it is
more effective to divide it, into three parts
identifying them as measurable
supplementary objectives (Figure 1).
These objectives are related to
characteristics of complexity, and more
specific to those that demonstrate
healthcare’s specialties based on
literature. This helps current study to
apply a more concrete approach to
healthcare and conclude on results more
accurate and valuable in relation to the
overall aim.

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Figure 2. The Research Questions’ Framework of the study
(this Framework is used as a guide for interviews and data analysis)
3.4 Overview of the study (the structure)
In the current section (Section 3), there are presented the overall aim as well as research
objectives and research questions of the study. In this section actually, is defined the framework of
current research upon which literature review (Section 4) and methodology (Section 5) are unfold.
Literature review analyses and discusses the issues of:
• Complexity and healthcare
• Characteristics of complexity
• Healthcare’s complex characteristics and
• Greek economy
Literature review (Section 4) starts with the approach on complexity context and discuss the case
of Greece both in overall and healthcare sector issues. In Section 5, is given in detail the
methodology describing in steps the process of sampling, data collection and data analysis.
Section 6 refers to ethics. Section 7 gives findings of the survey and discussion in correspondence
to research questions framework. In the end, are given the conclusions of the study comparing
results with literature and giving some elements for further research (Section 8).
Research Questions’ Framework
Information asymmetry: does this exist among the agents of the healthcare sector and
especially among the providers of the services, the receivers of the services and the
payers of the services? (Agent-based nature)
Interdependencies: is information asymmetry a source of high interdependence among
agents? Are there any weak links created through interdependencies? (Connectedness)
Heterogeneity: is there considerable professional and technological heterogeneity within
healthcare organizations? Does this create difficulties in understanding the organization
and the sector in extent? (Emergent dynamics)
Attractor patterns: how the system reacts and responds to certain issues of change? Is
there any paradox regarding absorption of changes within the system? Does the system
respond as a whole or diversified? (Emergent dynamics)
Generative relationships: is this a special complexity characteristic of healthcare sector?
Who defines such relationships? Does this affect the behavior of agents? Does this affect
the healthcare service itself? Do the specific relationships create contexts?
(Connectedness)
Collective reflexivity: how this works within the sector? Is this a derivative of complexity
thinking? Can this be further exploited? (Emergent dynamics)

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4. Literature Review
4.1 The structure of Literature Review
Literature review follows a four-pronged approach, which is extended in: (a) to present and
discuss the characteristics of complexity and complexity thinking (section 4.2), (b) to bring forth and
reveal the relation of complexity and healthcare (section 4.3), (c) to identify and discuss the
characteristics of Greek recession, including historical economic data (section 4.4), and (d) to
discuss practicalities that could help the sector to define its complexity space and apply complexity
thinking in terms of emergence and self-organising towards resilience and rebound (section 4.5).
This structure aims to reveal the path-dependence of healthcare sector in times of crisis, and
how this is affected by the complexity metaphor.
4.2 Complexity
Holistic approach is still not a popular practice, especially in terms of analysis and synthesis of
concerns and decisions. When new challenges are ahead, behaviours are more adaptive to
complexity and follow similar adaptive cycles. The attempt to apply machine-metaphor thinking in
dealing with complexity brings consequences of frustration within the system. Healthcare systems
are not linear and additive. Therefore, their dynamic could not be obtained by summing up their
parts. McDaniel and Driebe (2001) claimed that no one is smart enough to figure out where the
healthcare system is going at any level. Both investors and practitioners are trying to predict the
future of the healthcare, aiming to discover the component that will prosper. Besides, Beautement
and Broenner (2011) have concluded that the evolution of the system is unknowable.
4.2.1 Growth and Degrowth within Complexity
What Greece experiences is possibly a small part of a wide change. This is how the country
confronts, within its microcosm, to a bulk of consequences stemmed from the change in global
strategies. Yet, is normal claiming that the motives are planetary wise, implying the ultimate
humankind’s sustainability.
Donella Meadows (1995) defined as sustainability the equilibrium of co-existence between
humanity and the planet. Such target incorporates the essence of the “complete vision”, as she
claimed, which necessitates the components of spirituality, of community, of decentralization, of a
complete rethinking in the ways humankind is accustomed to do things. One could also say that
there is a missing component in the above; this is solidarity, a historically common link especially in
tough periods. Meadows (1995) clarified what sustainability means, by providing the following
explication:
1. Renewable resources shall not be used faster than they can regenerate.
2. Pollution and wastes shall not be put into the environment faster than the environment can
recycle them or render them harmless.
3. Non-renewable resources shall not be used faster than renewable substitutes (used
sustainably) can be developed.
4. The human population and the physical capital plant have to be kept at levels low enough
to allow the first 3 conditions to be met.
5. The previous 4 conditions have to be met through processes that are democratic and
equitable enough that people will stand for them.
Nevertheless, it is difficult to realise how democracy co-exist with control of human population.
Years earlier, a scientific team delivered a report to the Club of Rome (Meadows et al, 1972)
which briefly concluded that if humanity would maintain the same growth trends in a series of
resultants, the limits to growth on this planet will be reached sometime within the next hundred
years. This report was submitted on 1972 and it was the first time identified, that, infinite creativity
has to confront with finite resources. This perception coincided years later, with the recently
introduced green policies and the discussions on ecological footprints. There is a global challenge
though that humanity follows an exponential growth in a finite and complex system. In these terms,
Meadows et al (1972) were not restrained in identifications. They have recommended that if growth
trends could be altered and stagnated in a state of global equilibrium, probably this could rebound
sustainability.
As Maskin (1983) highlighted, according to Nash equilibrium, each player is expected to decide
on his social choice rule taking into account the decisions of other players. This brings equilibrium

8

in a game where all powers find their position. The rapid population growth, the industrialisation,
the depletion of non-renewable resources and the deteriorating environment, constitute an
explosive mix which obviously jeopardises human evolution and raises increasing entropy just like
the ice-melting in a warm room. Entropy appears when an entity starts to lose its cohesive
attributes towards elimination. Under such circumstances, de-growth, slowing down development
and re-orientating could be the alternatives.
De-growth, non-growth or even a-growthism are not newly introduced ideas. The bottom line of
cultivating future expectations for a society is reminding to the local powers the meaning of their
existence. It is probable that most of the times fear, greed and wishful thinking were hidden behind
the modern practice of grasping opportunities for the benefit of growth. Newman (2011) presented
his thoughts on the sarcastic question if finally “we live too many on this planet”, implying that may
have come the time to reconsider our population models. Population bombing and the link with
environment is not recent. Ehrlich (1966) introduced the IPAT Model in his effort to simplify the
understanding of humanity’s impact to the planet. Much discussion is raised since then, whether
such approach is adequate and scientifically valuable. Nevertheless, it is well-admitted that he, at
least, tried to establish a set of measures in the perception of impact (Figure 3).
Figure 3. The IPAT Model
It is interesting that Ehrlich, well early had identified that the derivative of affluence and technology
as means used by the population, had direct environmental impact in a measurable way.
Either following growth or de-growth models, it is imperative for any power to develop a set of
relationships within these parameters, in order to promote its policies. It is notable that the model
was introduced in early ‘60s where technology had not yet achieved global penetration.
De-growth is not a policy rather than the mediatory situation between recession and growth. As
Georgescu-Roegen (1971) claimed in his study on entropy law and economic process, de-growth
is inescapable. Many years later, Latouche (2004) brought forth the issue again using the term
contraction economics, to describe as de-growth the deconstruction of the matter of development.
De-growth is not a practice rather than a guiding principle, which contradicts to growth being one of
the doctrines of modern economics. It aims to present an alternative path which directs to self-
sufficient and materially responsible societies.
4.2.2 The relation with health and healthcare governance
Healthcare is considered one of the most valuable pillars for a society to sustain and progress in
the global terrain. Since human capital and human intelligence is accommodated and protected

9

through healthcare practices, any external or internal shocks that generate crisis reveal sector’s
vulnerabilities. From industrial age to knowledge era humanity have experienced various cohesion
and survival shocks. According to Naomi Klein (2011) there are three ways for a society to change.
These are: due to natural disasters, wars, and economic burdens.
Nevertheless, modern times revealed that societies still have not yet seriously confronted with
the diminishing health value of their members but they will. Further to knowledge era, the challenge
is expected to be the welfare epoch. Regions that will keep the healthiness of their human capital in
high levels are expected to acquire a unique advantage and opportunity for further progress.
Therefore, healthcare would be an asset to escalate competition and create new terrains. In a
continuous changing global environment, health governance plays the role of trustee who
undertakes the responsibility to protect the rules of progress.
Adopting Walters (2001), there is a suggestion to embed the mindset of building blocks health
innovation. The building blocks of health innovation could aim to raise the powers of survival
through certain practices such as:
• Implementing national welfare reforms
• Using information technology
• Pursuing process improvement
• Enlisting the help of both public and private sector
• Empowering communities (citizens)
Current study intends to accommodate further knowledge on this area given the case of Greece
and the experiencing recession having impacted strongly the healthcare sector. Globalisation has
brought strategies, which direct regions towards standardization and homogenization. Societies
that will be unable to comply will experience a much more sharp alignment or isolation.
4.2.3 The search-for-equilibrium
Daskalakis et al (2005; 2006; 2009a; 2009b) discussing the element of equilibrium in complexity
concluded that in a game there is always equilibrium. May be the equilibrium is the complex system
itself, and the challenge remains in exploring the rest of the game. Complex adaptive systems
(CASs) are strongly experiencing change, emergence and co-evolution as phenomena which
constantly push the system far from equilibrium. This happens due to players’ willingness to
change or not to change their behaviour, based on their motives (Daskalakis et al, 2009a; 2009b).
In such a case, there is no optimal solution, but putting complexity to work while being alerted and
ready for action; an action which stems from the capacity to learn.
Complexity is bind to far-from-equilibrium status. Nevertheless, for a real economy to rebound, it
is necessary to achieve a level of stabilisation rather quickly. Any change should be performed
effectively and transitional period should be of minimum length. Even if the society decides to
bounce back as a result of its resilient practices, the request is to acquire stability. On the other
side, in case the society bounces beyond, by changing structures and not roles, again the end-
process is expected to be the search of stability. Therefore, economic stability remains as the
primary objective since this, by itself, activates a series of positive consequences such as increase
in foreign direct investments, high reserves, stable interest rates and business expectations. The
main problem of Greece currently is economic instability. The situation as described in the previous
section briefly creates a framework consisted of: fear-uncertainty-high risk. The stability mix, which
may help the country to return quickly, is depended on (Figure 4):
Figure 4. The factors of stability mix
1. Anti-cyclical monetary policies
2. Debt management
3. Fiscal adjustments

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The participation of the country in Eurozone, a currency consortium, demonstrates both
advantages and disadvantages in this specific case. Euro is considered as tough currency. Taking
into consideration that the use of a currency mirrors the status of an economy, Greece has a
challenge ahead to confront. On the other side, the common currency between countries usually
leads to lower volumes of trade especially when these transactions do not create overvalue.
Therefore, in broader terms, countries tend to look for markets with different currencies and
variable exchange rates. In this case this is not possible. Greece belongs to the complex adaptive
system of Eurozone, and as such should be treated and researched.
Undoubtedly, monetary policies have direct impact to economic developments and the shape of
business environment. Changes in the stock of money affect the economic activity interfering with a
lag which creates cyclical fluctuations. Moreover, monetary policies could be exploited as
leveraging tools for the countries. The practices of devaluation and overvaluation usually help the
economy to adapt into broader changes following a cycle of recession-development. On the other
side, monetary policies can be used as a mean to impose structural reforms, especially when this
follows external shocks for an economy. This fits more to a “white-page strategy”; creating shocks
and vibrating an economy trying to eradicate old status quo; turning a new page in its economic
history and accomplishing a reposition.
Real economic progress comes at a price equals to creative destruction. Joseph Schumpeter,
who first identified and linked the essences of creative destruction and destructive innovation,
highlighted that both undermine human values. Moreover, he asserted that entrepreneurs, no
matter where they operate, they are agents of a system and they unleash innovation and creative
destruction. Therefore, it is almost impossible to look for equilibrium in an environment where the
phenomenon of entrepreneurship exists. This is what Pichler (2010) alternatively defines as the
ever-self-renewing entrepreneurial drive. Besides, he insisted that a reproduction of a system
stems from its own forces, and from within.
Borrowing definitions from criminology, the perfect guilt elevates when there exist three
parameters: (a) motive, (b) mean, and (c) opportunity. In correspondence, these could be in this
case: (a) motive: to activate changes, (b) mean: the monetary policy, and (c) opportunity: the
economic recession.
Understanding complexity seems close to managing change, managing crisis situations and
realising the structures of a living entity. In an extent this is useful to realise the complex system of
a country as a whole, especially when this experiences a time of recession and economic shock.
4.2.4 Complexity and Complex Adaptive Systems (CASs)
As mentioned earlier, complexity science focuses on dynamic states that emerge in systems
that find themselves in far-from-equilibrium status. The essence is the search and study of
characteristics in such systems. This finds application in the study of patterns and relationships as
well as the results of the interactions among the components of the systems. In complexity, this
happens in a holistic view rather than a simplistic way. McDaniel and Driebe (2001) discussed the
reductionist perspective, known as the Newtonian, which tries to understand the whole of a system
through the understanding of its parts. Things can be broken into their constituent elements in
order to be examined. This adapts to the mechanistic view of evolution, where systems are
confronted as machine-like entities and run-like-a-clock is the dominant metaphor. Batty and
Torrens (2001) defined as a complex system, an entity which is coherent in some recognizable way
but whose elements, interactions and dynamics generate structures. They have recognised the
existence of surprise and novelty in such systems, which cannot be defined a priori. Therefore, a
complex system is more than the sum of its parts since it accommodates numerous interactions,
dynamics and behaviours inside. The part, cannot replace the whole.
Various researchers (Hassink, 2010; Simmie and Martin, 2010; Clark et al, 2010) have
attempted to understand complexity and complex systems through research of natural systems. A
complex system demonstrates the attributes of a natural living system which incorporates different
sub-entities with powers, links and concern. In other words, this could be perceived as the biology
of business. Organisations, regions and countries has yet much to learn from biology and nature.
Complex adaptive systems (CAS) are self-organised systems which have the ability to adapt to
any external affection including the radical change of inner structures, if necessary. Scott (2008)
raised the issue of cooperative behaviours which could exist among the agents of a CAS. This is
necessary to progress, if the system prefers to survive. Therefore, although a CAS demonstrates
different dynamics and norms within its own substance, there must be some simple rules to
survive. As Janoff-Bulman (2009) highlighted, although a self-regulatory environment seemed to

11

gather many advantages there is always the issue of who will undertake the complex thinking.
Begun et al (2003) gave a concise definition of complex adaptive systems as follows:
Complex implies diversity, a wide variety of elements
Adaptive means the capacity to alter or change, the ability to learn from experience
System is a set of connected-interdependent agents
Complex adaptive systems can respond in more than one ways to their environment, although
they hide a sense of unknowability, implying the high risk of unexpected outcomes. This
incorporates the elements of extensiveness, process and surprise. Moreover, it complies with
emergence, differentiation and path dependence, as it was raised, by Schneider and Somers
(2006).
4.2.5 Characteristics of Complex Adaptive Systems
It seems that complexity is born from diversity. And there is no better way to understand
complexity than studying its characteristics. No matter the behaviour of a complex system and the
response to the environment, there is a certain number of characteristics that this owns. In the next
figure it is provided a small diagram of these characteristics (Figure 5).
Figure 5. Characteristics of Complex Adaptive Systems

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Some of the characteristics may encrypt greater significance (e.g emergence, self-organisation),
than others (e.g. history), but here is considered crucial to cover them all equally. The aim is to
bring forth and analyse these characteristics, taking into consideration any specialties and what
these represents. Catching the essence of characteristics enables the ability to understand
complexity as well as the difference between mechanistic and holistic approach. The intention is
not to deepen rather than use them as a guide to discuss the case of healthcare in the country.
Complexity stems from diversity. According to McDaniel and Driebe (2001) diversity is the
source of novelty and adaptability and in extent the source of invention and improvisation. All four
attributes are living elements of complex adaptive systems which are made from a large number of
agents. Easton and Solow (2011) specified that CAS consist of agents who act and react based on
self-generated stimuli, and the actions of other agents, either from inside or outside the system.
This agrees with what Daskalakis et al (2009a; 2009b), as discussed in previous section, had
identified regarding the game theory and the potential behaviour of players. Definitely agents are
the central actors in the system and demonstrate a dynamic state (Begun et al (2003). The
specialty though is that none of the agents can understand the system as a whole, since they tend
to attend their local environment (or microcosm). Therefore, none of them can acquire central
authority to manipulate the system; there is no central agent. On the contrary, they act and react
with each other and adjust their behaviour accordingly. In terms of diversity, although this could be
a positive source for the system, this in the same time may be a source of frustration among
agents. Diversity raises difficulties in communication, perception and stimuli. Psychogios (2011)
highlighted that agents select with whom and how they will interact. Therefore, they have an
embedded the element of selective behaviour.
There is an ingredient which links agents with the system and this is: information. Agents are
information processors who exchange, evaluate, and feedback information among them and with
other systems. Information on the other hand, is the blood of the system, which enables reactions
and defines concerns. Complex systems demonstrate acute similarities with living organisms.
Human beings are social entities who tend to organise themselves in a manner that is considered
approved and necessary for their survival. In complex systems this practice is expressed through
building blocks. During the evolvement of the system, different agents, based on their role and level
of pervasion are grouped and form various blocks. As the system unfolds the blocks change their
reaction and behaviour. So far, it is realised that agents do not only interact, but they adapt and live
in a complex system while they co-evolve with it.
Co-evolution does not necessarily imply progress, since agents may experience obstacles
which raise conflicts between them. In any case, co-evolution is the development of the system
through time under the prism of the micro and macro environment. Moreover, co-evolution
incorporates the actions of agents as a result of their own evolution within the system (nested
evolution). Any change that an agent introduces is expected to affect existed patterns and
relationships. This triggers the environment in a manner that other agents are obliged to
demonstrate functions of placement and repositioning in the new-formed framework. This action is
what McDaniel and Driebe (2001) identified as, the fitness landscape. Nevertheless, it is
questionable which might be the ultimate fitness landscape for a complex system, since there is no
agent that owns the big picture of it. This is probably a reaction of compromise and cooperation
that agents express, as a result of finding a workable solution for the system to continue evolving.
In this case, it could be claimed that the structure of a system is the result of the interaction among
the agents and their environment both the micro and the macro.
The essence of complex adaptive systems is encrypted in the relationships among agents.
Such relationships form a framework of interconnections which affects not only the agents within
the system but the system’s broader environment. Interconnections among living organisms, such
as organisations, show a stratification of connectedness. In other words, it is not only the number
of interconnections among agents but the richness of these connections that determines the
character and the behaviour of the system.
Besides that, relationships follow patterns which have been established through interactions
and such patterns enfold certain dynamics. Begun et al (2003) claimed that relationships among
agents are complicated and enmeshed, one could also say, these are massively entangled. Further
to this, Psychogios (2011) explained that relationships among agents are non linear, thus a small
stimulus may cause a large effect or no effect at all. Also he ascertained that actions and
behaviours of small non-average groups may result in unintended consequences. Non-linearity is
the ingredient of complexity. Due to partly non-linear input-output functions, complex systems
demonstrate unpredictable behaviour (Keune, 2012).

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In the same way, McDaniel and Driebe (2001) discussed that inputs are not proportional to
outputs as simple deterministic equations may produce an unsuspected richness and variety of
behaviour. However, complex and chaotic behaviour may enable ordered structures and
relationships play an important role in this case, especially when these relationships are mostly
received from near neighbours (Psychogios, 2011).
This in simple terms describes the range of interaction, but more important explains the range of
influence among agents. The use of information, either through positive or negative feedback,
either distorted or in plain terms, affects interaction and influence. Although these rules sound
simple, complex behaviour can emerge from such rules. Openness is an additional characteristic
of complex systems and this stands closer to patterns of interconnection and relationships. The
exchange of energy and information opens the width of complexity. It is interesting though, that
Begun et al (2003) had a different conclusion. He claimed that complex adaptive systems tend to
maintain in general bounded behaviour regardless the small changes in initial conditions. This is
called an attractor. Probably he saw that behind complex situations there are simple rules hiding,
in terms of self-organisation. He doubted also the generality of butterfly effect. The sensitivity to
certain small changes in initial conditions is depending in the exact path that the complex system
follows. So, emergence is not only the product of context-dependent non linear interactions but
also a product affected by the lock-in path, the path that the system will decide to follow. This is the
ultimate behaviour of healthcare sector in Greece. An attractor pattern which denies to absorb
changes and in response they build a lock-in path.
Keune (2012) defined emergence as a phenomenon that comes from the presence of simple
components in a system that interact in a manner which cannot be explained by their individual
characteristics. As a result, emergence is the source of novelty and surprise and this is one of the
most critical characteristics of complex adaptive systems. Actually, emergence stimulates new
structures and behaviours. It is not unrelated to other characteristics. On the contrary, according to
Psychogios (2011), new structures may emerge in a CAS, as a result of the patterns of
relationships between agents. Interconnection, co-evolution and their inner elements may direct to
emergence. The level of connectedness among diverse agents, in relation to agents’ building
blocks practice, and the properties of the system create a fertile ground for repeating emergence,
based on unpredictability.
This is usually the stage where resilience comes up as reaction. There is hidden power in
complex adaptive systems, and this is due to the ability of allowing a massively entangled group of
diverse individual agents the freedom to be adaptable and resilient (Easton & Solow, 2011).
Nevertheless, resilience has different natures or types. Hassink (2010) presented a four-dimension
model of resilience assuming that a system always tends to find its equilibrium; these different
types of equilibrium are: (a) the back to normal equilibrium, (b) the flip from certain equilibrium to
another, (c) the path dependent equilibrium, and (d) the long-term equilibrium.
Hudson (2010) verified that resilience denotes the capacity of ecosystems, individuals,
organisations or materials to cope with disruption and stress and retain or regain functional
capacity and form. Therefore, although this is not incorporated in the characteristics that have been
described so far, resilience is diffused as a mindset in the whole of a complex adaptive system.
Above all, it is related to exogenous shocks and reflects the system’s capacity to absorb
disturbance and reorganise while undergoing change (Bristow, 2010). Simmie and Martin (2010)
claimed that the primary ingredient of resilience is learning and in extent the capacity for a system
to have mechanisms of knowledge acquisition and knowledge assimilation. Systems that do not
succeed in capitalising knowledge will experience harder conditions in their effort to apply changes
and to align with broader necessities.
The collective result of non-linear interactions among agents brings new structures and
establishes new patterns of relationships and behaviours. Since complex adaptive systems are
dynamic, most of the times depending on their motives, they follow a path of self-regulation. This
happens, when agents decide to shift and change both internally and externally affecting each
other (Psychogios, 2011). They demonstrate a self-organising behaviour which an adaptive
response to the new situation and the new emergent properties. This is called self-organisation
and is considered one of the important characteristics in complex adaptive systems. It is the
situation where new status is adopted and the system operates through new patterns in a holistic
way. There is no central body to administer this transformative situation but this arises as a new
generated order.
Moreover, a complex system, as a living entity, has a history which cannot be ignored. Among
others, such systems demonstrate temporality, meaning that they are reflecting their history, their
memory of the past, in a selective non-linear manner (Keune, 2012). History should be considered

14

crucial in the effort to recognise and analyse other characteristics, since may hide repeating
behaviours, attributes, reactions and structures. As mentioned earlier, complex systems own the
problematic attribute of reduction. Any knowledge available for the system is nothing more than a
reduction of its complexity; a micrograph; a simplification.
4.3 Healthcare and Complexity
4.3.1 The Complex Characteristics of Healthcare
Healthcare systems demonstrate different specifications and characteristics. They are complex
adaptive systems which have their own specialties and distortions, usually generated from the
dominant metaphor of unknowability. Traditional administration in such systems still focuses in
control which is defined by the following scheme: (a) better regulation, (b) financial restrictions, and
(c) punishment of offenders (when possible). However, relationships and interconnections are
critically important since healthcare incorporates many diverse agents. Besides, this is the
challenge of the specific sector. There is a structure in the system but with variations.
In this section it is intended to bring forth some of the special characteristics of healthcare
complex adaptive systems. It is considered that these characteristics are responsible for the
differentiation of healthcare and the demand of a holistic approach rather than a common complex
system.
Probably the most important special characteristic of the system is information asymmetry
among agents. This applies between clinician providers of services and typical agents (patients
and others) (McDaniel and Driebe, 2001). Such asymmetries create interdependencies. No matter
if healthcare is offered through public or private services, there are weak links among the main
agents in this service experience, as figured below (Figure 6).
Figure 6. Healthcare services (agents’ links)
There are three major agents in healthcare complex adaptive system depending on their role.
Service providers are the one who holds inside information and this, by itself, position them in an
advantageous place. Service payers may be either the same with service recipients (in case of
private sector) or different (in case of public sector). In the former, the patient has a more direct
participation while in the ladder this is more or less indirect. According to relationships and patterns
of behaviour, as provoked via power, the links among these agents are varied. Potential
weaknesses in links lead to distortions.

15

Pisek et al (2003) highlighted that relationships is the central component to understand the
system. The behaviour of the system is the result of the interaction among agents. To be precise
these are generative relationships, meaning that these mainly affect the system. Furthermore,
actions of the agents are mostly based on internalised simple rules and mental models. For
example, the specialty of the relationship, developed between doctor and patient may direct in
actions that follow instincts, constructs or mental models rather than predefined rules. The
emergence of a case in Emergencies Section of a hospital stimulates initial instincts and puts aside
administrative rules.
Besides that, the system enfolds attractor patterns which define the response to certain issues
of change. Pisek et al (2003) for example, discussed the desire for autonomy as a strong
attractor pattern. However, there is a paradox in healthcare and this stands in opposite practices
that can be found simultaneously. There is one side in the sector which continuously adapt to
changes, while the other side demonstrates a remarkable resistance. Non-linearity is inherent since
healthcare accommodates nested complex systems. A hospital is a complex system embedded in
a regional healthcare complex system, which in extent is part of the national healthcare complex
system and so forth. Imagine that these systems co-evolve.
Additionally, there is considerable technological and professional heterogeneity within a
healthcare organisation (McDaniel and Driebe, 2001). Such heterogeneity increases the difficulty of
understanding the agents and the system. As Orr et al (2006) mentioned, two agents of the same
system (regional healthcare organisation) may approach the same problem in a different way and
with different resources, getting into different conclusions. For example the forthcoming problem of
ageing population, is confronted differently by Public Health System and Ageing Networks.
Experimentation and pruning is an ingredient of the system but it seems that applies to specific
cases and not holistically. Lessard (2007) argued that complexity thinking is a characteristic of
the sector but has to be collective. He introduced the issue of collective reflexivity as the mean
that should be taken into account in terms of changes. Quantitative methods are not enough in
assessing sector’s results. On the contrary, healthcare needs to deal with complex social problems
through multiple factors mediated by individual and social contexts. Tradeoffs across multiple
objectives and perspectives of different stakeholders are parts of critical thinking in complexity. On
top of all, concern should be given that decisions are strictly connected to human lives, quality-of-
life and health of human capital.
These represent the so-called ethical climate. Mills et al (2003) have placed ethical climate as
the decisive factor which either can endanger or empower the whole sector. She insisted that cost
constraint and quality improvement cannot co-evolve. In the same manner, she claimed that
placing sales techniques and market solutions in healthcare changes the nature of the service to
market commodity rather than a social service. However, cost strategies and relevant measures
should be placed carefully towards services’ nature.
On the other side, healthcare systems financing is a considerable issue for World Health
Organisation, as rising healthcare costs is the current challenge in global measures. The
Organization through various surveys and reports concluded that 20-40% of all health spending is
wasted inefficiently. Therefore, improving efficiency is the main target. Certain actions are
suggested, which involve: (a) better procurement practices, (b) broader use of generic drugs, (c)
better incentives for providers, as well as (d) streamlined financing and (e) efficient administrative
procedures (World Health Organisation, 2010). Such recommendations obviously provoke industry
and systems’ restructuring not only in Greece.
The socioeconomic position of a country has a direct impact on its healthcare strategies (Davey,
2000). Poor strategies raise inequalities and diminish worthiness of human capital. When a system
accommodates human beings, these have the freedom and ability to respond to stimuli in many
different and unpredictable ways (Mills et al, 2003). Consequently, the relationship between
environment and healthcare is the most challenging complex field, since contexts and relationships
are ignored or marginalised in the attempt to make economic evaluations. Batty and Torrens (2001)
highlighted wisely, that a complex system is one that can respond in more than one ways to its
environment, revealing the mutual relationship between such systems and their environments. This
statement incorporates the elements of extensiveness, process and surprise. Moreover, it aligns
with emergence, differentiation and path dependence, as it was raised later in 2006, by Schneider
and Somers (2006). To this extent, emergence and non-linearity show an even sharper behaviour
in healthcare; especially when unrecognised patterns reveal and unpredictive agents emerge
without authority, but with power that stems from structural changes.
It is a matter of conceptualisation and how healthcare is perceived in terms of metaphor
(complex or mechanistic). The most complex systems are social systems and healthcare sector is

16

the most complex within this sub-domain (Begun et al, 2003). Further, resilience fits the
complexities of healthcare more effectively than principles of high reliability since this provides the
framework to learn and adapt (Jeffcott et al, 2009). Complexity accommodates the view of human
error and is the result of an environment that is fraught with gaps, hazards, trade-offs, and multiple
goals. In addition, in the centre of it remain erratic people who have their personal initiatives.
4.4 The case of Greece
After ten-years of seemingly strong growth, Greece started to experience the effects of the
global downturn in early 2009. The large fiscal deficit from the one side and the external
imbalances on the other side (the twin-deficits), have revealed the chronic vulnerabilities of the
national economy.
Greece is a country member of the European Monetary Union (EMU) – using Euro, officially
adopted since 2001 - with approximately 11 million inhabitants but 5 million of labour force, till the
end of 2010. By that time, and since the country enters crisis this number is declining to less than 4
million, and so forth. According to calculations included in the recently issued Greece’s Public
Budget for 2013, the unemployment during 2012, has reached 23% while the forecasts for the next
year exceeds 25% (Stournaras, 2012). A significant percentage of the labour force still is consisted
of immigrants especially in sectors that are considered crucial for the country’s economy
(constructions, tourism, agriculture etc.), mostly in primary sector. Less than half of the registered
population belongs to what-so-called economic active population. Regarding synthesis of country’s
domestic product and the labour force, in very general terms, 65% is occupied in services, 23% in
industry and the rest 12% in agriculture.
4.4.1 Historical economic data
Although the country in early 50s had been characterised by an increasing development in
agricultural and industrial sectors, the gradual incorporation in European Economic Community
(EEC) towards 1981 (year of official entry) (European Union, 2012) was the main reason that
switched its orientation primarily to services. This directed in experiencing a de-industrialisation and
an emphasis in non-intensive agricultural products.
The country experienced an enormous growth in the period of 1953-1973, hitting the upmost
performance in the decade of 1951-1961 (Bowles, 1966; Delipetrou, 2012). In Appendix A is given
a comparative table registering the country’s GDP growth rate on that period, placing the country in
the second place in the post-war advanced economies. Maintaining a growth rate of 6.1%, Greece
was, with Italy and Germany the drive-wheel of Europe’s reconstruction. In Appendix B is given the
distribution of the country’s growth rates per sector. Energy, construction and mining were the
driving forces of country’s rebound.
During 1961, Greece reached the enormous 11.15% GDP growth rate. The following years until
1973, the growth rate was ranged from 5.5% to 10% annually (Indexmundi, 2012). This positive
tension sustained until 1980 (0.68%) with the exception of 1974 (-6.44) the year of state regime’s
change. It is strange though, that although the country had experienced a series of political
instabilities during that period, the economy had demonstrated strong characteristics of resilience.
Nevertheless, starting from 1981 the country had been experiencing low growth rates
comparing to previous years (around 3%) and even negative ones until 1999. The year of 2000
was linked to the Eurozone. The growth rates from 2000 to 2007 were positive, ranging
approximately from 2% to 6% remaining very close to other European economies. Suddenly, since
2008, the growth rates were negative following a sharp decline reaching the surprising -7%,
probably the highest de-growth rate in the Greek economic history for the last 60 years. Ever since,
the country is facing a gradually deep recession.
In the same way, unemployment followed the GDP de-growth rates. In Appendix C, Demekas
and Kontolemis (1997) present the unemployment rates in Greece which were considered the
lowest in OECD countries especially prior to 1970. The foreign direct investments during that
period were kept in high percentages since the state had demonstrated a clear will to support the
capital and distribute the agglomerated premium both to investors through returns and to the labour
force through social policies. Therefore, investments brought capitals which cultivated in extent
social relationships in the country and enabled an environment for future social concerns. Probably,
one of the determinants which played a significant role in keeping foreign investments in the
country was that these were protected under definitive strict laws.
The development had been based primarily in external economic help from USA and rich
European countries (the Marshall Plan) in combination with an internal 4-pillar source of financing
originated grom: (a) remittances, (b) maritime exchange, (c) tourism, and (d) export of agricultural

17

products. These four sources created the basis for further evolvement of more sectors which
contributed to the country’s GDP.
Greek economic history has demonstrated that the country always based a significant part of its
progress in external loans (Romaios, 2012). In addition, there were always consortiums of local
industries which supported development plans; this, in combination with the independent monetary
policy and economic tools that the government exploited, they were used from time to time, either
to absorb any fiscal pressures or to boost economy. Furthermore, the country had acquired strong
placement in the global terrain, in a series of products and services. The country’s product (GDP)
consisted of a set of individual end-products which contributed to the final formation. In other
words, there were multiple sectors to depend on, and make economic policy.
4.4.2 Recent economic situation
Further to Eurozone enter, and rather gradually, the country experienced a loss of
competitiveness, as that was identified by its EU partners (Memorandum of Understanding of
Specific Economic Policy and Conditionality, 2010; Memorandum of Understanding of Specific
Economic Policy and Conditionality, 2012). Thus, the real exchange rate was considered
significantly overvalued compared to fundamentals. On the other side, local labour market was
considered to be relatively weak. Also, the employment rate was low and the unemployment
duration was among the highest among peers. Long-term unemployment turns to inactivity.
Structural impediments hinder product market performance such as: limited liberalisation of utilities,
insufficient internal competition due to high regulation, low ICT penetration, and high barriers to
entry in the market, especially in services.
Further to the above, EU partners and other economic organisations identified that the country
had one of the highest disparities between the number of public servants, as percentage of the
workforce, and their compensation as percentage of total compensation. The compensation of civil
servants in Greece was relatively high (OECD, 2010).
In terms of budget for 2009 revenues were of 109 billion dollars and expenditures of 145 billion
dollars. Exports were estimated in 21.3 billion dollars and imports around 64.2 billion dollars (CIA,
2010). The fiscal deficit reached 13% of GDP in 2009 (OECD, 2010). Public debt was about 100%
of GDP in 2008 and 113.4% of GDP in 2009 ranking the country in the 8th
place globally. Defence
spending was estimated at 4.25% of the GDP in the mid-2000s.
The country was considered as less developed than any other Eurozone country. At the same
time, it registered higher rates of growth and inflation than other member countries. This was due to
“a structural expensiveness” in the Greek market which still has an oligopolistic nature, with almost
the unique exception of telecommunications (Pelagidis and Toay, 2007). The product market
rigidities may be considered as the impact derived from excessive regulations, complicated hiring
burdens and mediating costs that are keeping bended any free-will for investments. Moreover,
there are serious obstacles in business activities due to bureaucratic issues. Such cases
encourage money laundering and financial crimes.
Besides, there is a determinant between growth and development. Although these are related
and co-evolve, this is not necessarily happens in a synchronous way, especially in the neo-
liberalistic economic model. In the case of Greece, the country for more than a decade had
demonstrated high indexes of growth but this was not penetrated in the real economy, which
mirrors the level of development. Actually the country, during this time experienced an
underdevelopment, which is a possible effect of modern practices adoption. Economies in their
attempt to update and align with modernised techniques may fall into underdevelopment.
Underdevelopment is the phenomenon of economic increase without development (Argyris, 1983).
Obviously, this was confronted in the case of Greek economy due to its high dependence on
distortions and restrictions, as well as other structural characteristics but most of all due to
paternalistic mindset. Another factor was that the country lost its membership’s economic
orientation in Eurozone. What exactly want the partners from Greece to produce? What is the
expected role of the country in Eurogroup?
According to Global Corruption Report 2009 (Transparency International, 2009), Greece was
placed in the 57th
out of 180 countries for the year 2008. Furthermore, a national survey presented
by the Transparency International Greek branch, for the year 2009, estimated that the size of the
total corruption (both public and private sectors) was increased at approximately 787 million euro,
comparing to 748 million euro for 2008 (Transparency International-Greece, 2009). Levels of
foreign investments remained low comparing to other OECD countries, as appeared in international
reports (Political Risk Services, 2009). Openness to foreign investment could be considered rather
restricted. Foreign and domestic investors face almost the same screening criteria. Foreign firms

18

are not subject to discriminatory taxation. Although there were various efforts to create a positive
environment for investments - such as the “Invest in Greece Agency” which operates as a one-stop
shop for assisting investments in the country – this, by itself was no more than a single attempt.
The lack of a stable law-taxation framework towards investments is the primary cause of investors’
aversion.
Greece’s economy had been subject to intense governmental regulation (Political Risk
Yearbook, 2009). Greek labour laws were restrictive in terms of working hours’ limits, flexible
employment (part-time, on demand etc) as well as hiring and dismissal of personnel (Political Risk
Services, 2009). At least this was the situation prior to Memorandums’ directives. The tax regime
lacks stability, predictability and transparency. The government often applied small adjustments to
tax levels and imposed retroactive taxation. Besides that, it is still difficult to measure productivity
especially in the public sector where there is no knowledge of what is the value of goods and
services offered, since there isn’t an evaluation framework. But there have started attempts for
improvement.
Nevertheless, it should be recognised that the country is currently making a strong effort to
change the existed economic environment - November 2012 - through a series of new laws which
aim to bring a radical restructure. The third memorandum of understanding, known as the Fiscal
Strategy Framework 2013-2016, approved on November 2012 by the Greek Parliament, changes
the structures in multiple levels trying to eliminate a series of distortions and cultivate a framework
for real development.
Greece had more or less a fiscal deficit of fifteen percent (15%) during 2010, the year that finally
entered in the first adjustment programme. The Greek government had to finance this deficit, in
other words find ways to ensure that accounts will be paid and cash flow will not stop. By that time,
growth had been financed by a private sector borrowing and a public sector borrowing and
spending. A significant income channel came from the absorption of EU structural adjustment
funds and the participation in a number of other EU programmes (Political Risk Services, 2009).
Now, during 2013, the country tries to balance its deficits and create a friendly and secure
environment, in order to rebound. In the meantime, continues to receive money from troika, as
agreed, through small instalments on certain periods and after thorough evaluation of progress.
4.4.3 Consequences
Over the last fifteen years the country has exhibited a remarkable record of growth and
monetary convergence with the euro zone which finally could not manage to exploit. Economic
expansion had been largely based in (a) the liberalisation of the financial sector (provide cheap
credits to households), (b) the reduction of interest rates due to EMU, (c) the migration inflows, (d)
the pervasion to the southeast European markets, (e) the growth in public investments, (f) the
inflows from EU programmes and (g) the consumption.
However, this growth - as mentioned earlier - was neither balanced nor in relation to labour
productivity, employment participation and technology adoption. This growth did not direct to
rearrangement of wealth distribution towards sectors that could lead further. Instead, the financial
sector’s liberalization and lower interest rates after euro adoption caused a demand booming.
Nevertheless, inflation and labour cost growth exceeded that of trading partners and eroded
competitiveness (IMF, Country Report, 2009). Imbalances persisted and in combination with the
global financial crisis, that had weakened sentiment and had sent spreads soaring, causing
financial scare. In addition, the lack of political consensus hampered any effort for effective policy
making (IMF, Country Report, 2009). Revenue shortfall and the rising expenditure widened the
fiscal deficit. In addition, the country felt the downturn beyond its own causes, due to Euro area’s
problems. Euro zone is still experiencing a recession, in terms of more countries that are facing
similar to Greece economic problems, although of different nature.
Greece is expected to further decouple. Main reasons are lower investments and low exports of
highly intense products, destocking and a decline in private consumption as confidence and
employment have dropped (IMF, Country Report, 2009). Inflation remains high with unemployment
rate reaching 24 percent within 2012. Uncertainty and high risks remain. It is questionable whether
local social partners will continue to provide support for changes. Although the optimistic climate
that is attempted to be created, numbers are still ahead. As Monastiriotis (2009) concluded, the
recent economic turbulence had proved that Greek economy suffered of structural problems and
weak fundamentals. Public debt, lack of international competitiveness, unemployment, eroding
public finances and a credibility gap, plus inaccurate and misreported statistics, are forming an
explosive mix which direct to economic instability (CIA, 2010). The falling state revenues and the
increased government expenditures are two more ingredients of this unstable mix which moreover

19

accommodates: tax evasion, inelastic government expenditures, an ageing population and an
unsustainable pension system. Structural problems are driving to low export penetration,
unemployment and inactivity, low labour mobility and wage flexibility, low technological absorption,
low educational performance (Monastiriotis, 2009).
Above all there is an economic duality which creates a framework; a given status-quo consisted
of (a) a large shadow economy and (b) a disproportionately protected public sector (Monastiriotis,
2009), which still the country cannot administer effectively due to the political cost and the probable
social explosion.
The fiscal position is further challenged from (a) the programmed reduction of European Union
structural funds and (b) the cost pressures from rapid ageing. The consistent underperformance on
applying the necessary structural reforms throughout the years will continue to lead in low
productivity. The imbalances of the Greek public sector are driven by multiple structural factors.
The dramatic rise of public expenditure and the inadequate control of government spending were
the main cause of the widening fiscal deficit (OECD, 2010).
The International Political Economy “think tank” had issued an article on the devaluation of the
Greek euro, where it was clearly presented the country’s exit scenario of the Euro zone, although
temporarily (Aliber, 2010). The Greek “product” is considered expensive, since costs are too high.
As a result it cannot stand in the globalized markets; it is less competitive and provides no
sustainable future. If there is no competitiveness there is no growth, according to the growth
models of globalised markets.
On the other hand, high costs lead to a massive current account deficit and among others
contribute to high levels of unemployment (Aliber, 2010). Unemployment directs to low level of
fiscal revenues. A bigger economy makes it easier to absorb aging costs and improves the
standard of living for all Greeks. Revenues need to increase and expenditures need to be cut.
Greece will face incremental difficulties in placing additional debt not because the past debt, which
has already been absorbed by the market, but because of the pressures from implicit future debt
under current policies (IMF, Country Report, 2009). The longer the government waits to adjust the
comprehensive net worth gap, the more difficult it gets, because the shortfall is projected to get
deeper every year.
4.4.4 Healthcare
Under this evolvement, healthcare sector was the first impacted. Various reports from global
organisations have concluded that Greek healthcare system demonstrated specialties and
monopolistic patterns which resulted in raising burdens to the country’s deficit (Davaki & Mosialos,
2005; IMF, Country Report, 2009; Memorandum of Understanding of Specific Economic Policy and
Conditionality, 2010; Memorandum of Understanding of Specific Economic Policy and
Conditionality, 2012).
On March 2012, Greek government fully adopted the Memorandum of Understanding on
Specific Economic Policy and Conditionality (2012) which was the framework including all
necessary reforms for the healthcare sector, to be implemented until 2015. The efforts were
directed mainly to the control of public pharmaceutical spending (Appendix D). More precisely
focus is given on (a) the reasonable pricing of medicines, (b) the monitoring of prescribing, and (c)
the increasing use of generic drugs (Appendices E,F,G). The target placed for the country was to
increase the adoption of generic drugs from 32% to 60% by the end of 2013. This target challenged
the existed system and was considered a direct intervention in how the medicines provision would
be administered. Below, there is an attempt to illustrate how the old and new systems work. This is
an eco-map of health operations in terms of pharmaceuticals provision to people (Figure 7).
The old system provided an essential independence on pricing and prescribing to the primary
system’s players, which were: (a) the pharmaceutical companies, and (b) the doctors. Government
was actually isolated in identifying health needs and approving budgets originated from the Public
Insurance Organization (EOPYY), who had a relative independence in administration and
budgeting. The system was rather a flabby one, with lack of controls and absence of appraisals.

20

Figure 7. Eco-map of the pharmaceutical provision system – public spending (old system)
For example, doctors acted as decision making agents by defining which type of drug will be
given to the patient. This practice though has global and old characteristics. Doctors’ behaviour in
terms of prescribing is based on information and incentives (Hellerstein, 1998). Such behaviour
incorporates the supplier induced demand. When decisions are originated from asymmetric
information and agent problem this creates social and health costs. Thus, the decisions are not
cost-effective. Nevertheless, in common practice, pharmacists often substitute branded drugs
prescribed by doctors with generics that are considered equivalent (Hellerstein, 1998).
In the new law there is an intervention to monitor the prescribing of medicines, and increase the
use of generics in order to decrease healthcare spending (Hellenic Republic, 2012). In the next
diagram (Figure 8), it is clearly demonstrated the change of roles and controls, as placed by
government. Nevertheless, such changes reveal weaknesses mostly originated from the inability of
public services to support effectively the altered operations. This stems from luck of budgets which
are necessary to protect the new legal framework.
The reformed system introduced a close monitored process where prescribing and pricing is
under continuous scrutiny. At this stage, primary market system’s players are: (a) the government,
(b) the National Medicines Organization, (c) the doctors, (d) the pharmaceutical companies, and (e)
the pharmacists. Pharmacists are the ones who will decide the generic in the new system following
the government rules. In the case of Norway, pharmacists demonstrate heterogeneity in drugs
decision which stems from their professional specialties (Dalen et al, 2011).
The new health system started its operation during summer 2012, with many problems and a
series of oppositions originated from the healthcare partners including doctors, paramedical staff,
pharmacists and healthcare products companies (Hellenic Republic, 2012; the new Healthcare Law
4052/2012). In simple terms the reform, introduced policies for:
1. Reducing and controlling expenditures in the pharmaceutical sector.
2. Instituting a single universal social health insurance organisation (E.O.P.Y.Y, the National
Organisation for the Provision of Health Services).
3. Reforming the hospital sector.

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Figure 8. Eco-map of the pharmaceutical provision system – public spending (reformed system)
These reforms were nothing more than the ones already approved in the first Memorandum of
Understanding, signed two years ago. Any laws and decrees since then were based on the above
three-pronged strategy.
Moreover, some months later, during November 2012, the Government approved the Fiscal
Strategy Framework 2013-2016, which went deeper in reforms regarding: (a) the stratification of
medical staff’s salaries, (not only), and (b) the pricing of logistics’ costs and procedures for the
supply of medical products and services. Nevertheless, the main structural health intervention for
the country is considered the one of the unique Health Association Organisation (E.O.P.Y.Y, the
National Organisation for the Provision of Health Services). This was done in the effort to centralise
and control inputs and outputs of the system. All transactions should be made electronically and
there will be periodic reviews (Greece, Fiscal Strategy Framework 2013-2016, 2012).
As it seems, November 2012, was a significant month for the country. The First Review of the
Second Economic Adjustment Programme, by troika, was published on that month, as a result of
the scrutiny which lasted for more than 4 months. The results were fairly disappointing. Lots of
work still is necessary to be done in terms of prior strategies. Public health expenditure should be
kept less than 6% of the country’s GDP. On the other side, the new structures should be more
efficient to maintain universal access to health services and improve the quality of healthcare
delivery (IMF-EC-ECB, First Review of the Second Economic Adjustment Programme, 2012).
It is questionable though, how this will be achieved in terms of human capital, meaning the
medical staff. The central idea of internal devaluation, as discussed in previous sections, affects
among others the labour cost. For example the payroll of doctors in public hospitals will range from
1,000 to 1,700 Euro per month (gross income), while the Institute of Labour in Greece, has
announced that the amount of 580 Euro (net income) is the poverty’s borderline.

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4.5 Demystifying Complexity
4.5.1 Using Complexity in practice
There is no ultimate model to suggest in the effort to use complexity as a one-size-fits-all
strategy. On the contrary, the intention is to combine and apply practices taking into account what
various researchers and practitioners have identified so far. Therefore, for each complex situation
there is a critical path to follow by joining its points to reach the end-result.
This practice could be applied both for independent or broader cases of complexity, probably
not only in healthcare. Recognising the specialties of each case, the practice will include the
following three-pronged cyclical strategy:
Figure 9. Practicing Complexity (perpetuity)
Zimmerman et al (1998), claimed that machine-metaphor is not adequate, in explaining complex
practices. The apparent compressions of space and time, as well as the series of thoughts
presented in the first section of this study, verify that there are strong connections of micro and
macro phenomena. Likewise, complexity seems to incorporate biology and technology.
4.5.2 Identify the Complexity Space
Characteristics of complexity can be used as a guide to start framing the complexity space.
Although complexity incorporates perpetuity, it is difficult for a human mind to capture something
obscure unless this has certain attributes. When practicing complexity there are certain elements to
discover, and can help in this attempt.
• Who are the central agents in healthcare CAS?
• Is a stakeholder analysis adequate to identify them?
• Which are the patterns of interaction among them?
• Is there any trust among them?
• Are there rich connections among agents?
• What is the level of connectedness (interconnections)?
• Are there any barriers?
• Which are the patterns of behaviour? Who defines them?
• Which are the interdependencies?
• Does the ability of alertness exist among agents to identify constant changes?
• Does the managerial ability exist to administer highly uncertain emergent properties?

23

The above could outline the framework within the system operates at present time and provide a
possible space that complexity exists. It is difficult to determine boundaries of the system in
complexity, since any attempt may raise ambiguities (Psychogios, 2011); but it would be practical
to conceptualise the system in concentric circles in order to prioritise in a sense the components
that are considered more important per case (Figure 10).
Figure 10. Conceptualising the Complexity Space (in healthcare)
Identification is imperative for realising and accepting the space of interest, the arena where
practically the system evolves.
4.5.3 Navigating in the Complexity Space
Easton and Solow (2011) have identified three key components to set the conditions for co-
evolving in complexity. These are: (a) the Healthcare Ecosystem, (b) the Impact Variables, and (c)
the Adaptive Change Cycle. It is almost inevitable to navigate in the sector unless the above are
put into practice and serious consideration.
Healthcare Ecosystem is the embedded dimensions of the sector including human capital. To
be more precise this includes the underlying patterns and context in which the healthcare sector
operates. It is necessary to recognise them prior to any introduction of change. The aim is to
perform the move from current to desired state with greater agility and fewer surprises.
Further to that, another weak link is the identification of variables that are more readily
influenced (impact variables). This could be revealed during the study of smaller changes and how
these take place within the sector. Such tactics help in uncovering patterns and in appreciating
current dynamics. According to Easton and Solow (2011), there are seven impact variables which
are the components of the activity in the sector (Figure 11).

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Figure 11. The 7 Impact Variables when navigating in healthcare sector
The intended or unintended affection in any of the specific variables influences the activities within
the sector. Therefore, it is crucial to assess and monitor each one, in case of a change.
The third key component is the application of adaptive change cycle. Co-evolving with
complexity implies a cycle of acquisition, adaptation, application, results and learning. This is a
dynamic multi-process which needs to be accommodated in an organisation especially when
changes are about to take place (Figure 12). Changes could be compared in regards to these
steps between prior and new-introduced situation.
Figure 12. The 5 steps for Co-evolving with Complexity

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This is an infinite operation, which starts from acquisition and ends in learning, as the ultimate
component for performing a change. However, it is questionable if learning corresponds to
knowledge. Here stands the difference between learning and knowledge. According to Simmie and
Martin (2010), economies are based on and driven by, knowledge. Knowledge is never static but
constantly changes. There is a certain distance from knowledge acquisition to knowledge
assimilation and how this is applied in practical terms. Therefore, the search of any equilibrium in a
healthcare organisation is an on-going process which involves knowledge and learning. Living in
the knowledge era successor of industrial age, new emerged structures come on top, especially
when new knowledge is acquired and this is accompanied by capital accumulation. This directs
living entities in performing faster the adaptive cycle, jeopardising their cohesion and questioning
their resilience limits, close or far from equilibrium (Figure 13).
Figure 13. The phases of adaptive cycle (through resilience and capital accumulation)
(Source: Simmie, J. And Martin, R. (2010) The economic resilience of regions:
towards an evolutionary approach. Cambridge Journal of Regions, Economy and Society, 3, p. 34)
Resilience is related to capital and both their progress follows supplementary paths during the
adaptive cycle. When the process of capital accumulation decreases, resilience follows an
increased path; it reaches its peak time during the reorganisation and restructuring phase of the
entity. Elliott (2009) highlighted that the process of knowledge transfer and assimilation, is a key
component for the learning framework in an organisation. He presented a mapping of this process
which is given in Appendix H. Although local forces or other barriers block learning, learning from
crisis directs to knowledge acquisition that depends on agents, and how they will handle and
acclimatize it- which ultimately may be translated into new norms and practices or plain history.
This is the phase where remembering or forgetting history plays its role.
Gaining knowledge on complexity is related to acting based on limited knowledge and ambiguity
(Keune, 2012). Navigating in a specific complexity space, such as healthcare, imposes dealing with
ambiguities and different types of dynamic behaviour, but towards rebound and sustainability.
4.5.4 Putting Complexity to Work
Easton and Solow (2011) concluded that since you cannot control a complex system you have
to understand how it works, thus penetrate in its DNA. Therefore, it is necessary to adopt the
mindset where patterns replace predictions and adaptation replaces control. Such strategy
incorporates the observation of conditions and the focus on patterns of interaction rather than
reified structures. As Sweeney and Mannion (2002) discussed, it is imperative to scrutiny the
healthcare system by investigating the coming together of the different elements that share the
environment, check their interconnection and reveal their purpose. They have identified complexity
as one of the fours generic types of dynamic behaviour that a complex adaptive system exhibits
(Figure 14).

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Figure 14. The 4 Generic Types of Dynamic Behaviour
In Complex Adaptive Systems
It is important to identify where the system stands and “play” with the corresponded dynamic
behaviour through emergence and towards self-organisation afterwards. Although it is not feasible
to control, it may be practical to affect.
Stasis, actually depicts the absence of dynamic behaviour, while Order depicts a behaviour
that is predictable, linear and stereotypical (Sweeney and Mannion, 2002). Chaos on the other side
is a behaviour which appears randomly but with hidden order and determinism. Further to this,
Complexity is the dynamic state, which operates as mediator between order and chaos. As
discussed in earlier sections, in complex adaptive systems, agents have a degree of independence
in terms of their possible actions. Adaptation and re-organisation cultivate a fertile ground to
produce emergent behaviours. Such behaviours tend to affect the system’s attractors, which
accommodate the practice of how things used to work so far. Thus, the heart of the healthcare
system is that attractors. The way these entities accept, and react to external stimuli defines the
behaviour of the whole system.
When changes are introduced, such entities tend to focus on what is going wrong in the system
during the transition phase; this is considered as a reaction of survival, trying to prolong their status
and avert risks. On the contrary, the healthy powers of the system focus on what succeeds and
investigate why this results so. This is a method to recognise the positive powers that contribute in
performing a plan effectively. Moreover, pushing emergence of new agents and introducing new
patterns of interaction and relationships, this in extent, moves forward self-organisation processes
and the system follows the lock-in path of change.
The way that the system deals with difference, defines its evolution in practical terms. One tactic
is to collect and review different viewpoints and accept criticisms. This is a way to test the
endeavour and define the ontological boundaries of the complex picture that is presented.
Checking the robustness of our picture stems from applying correctly the practice of integrated
assessment, focusing on stakeholders. This assessment could check four parameters; (a) ethics,
(b) the notion of power, (c) who are the actors, and (d) which factors are important and relevant. By
affecting one of the above, this might raise changes in structures.
Diversity is an important characteristic in healthcare complexity. The diversity of agents brings
heterogeneity which could be seen as an advantageous potential to exploit any stemmed
strengths. This diversity supports sense making, a useful strategy to follow for complexity. Sense
making is the ability to observe, to capture, to process information, to follow rules and to connect
and share with other agents. Therefore, it requires interaction. This strategy cultivates a collective
mind among agents who - in this way - can deal better with emergence and self-organisation.
Making sense of what you know in complexity is the replacement of decision making in

27

management, and stands forward from knowledge and learning. The capacity of learning can
replace control in such a system especially when this endures through time. Time is a key factor
and is strongly linked to the non-linear trajectory of the complex system.
Non-linearity is often the cause of time-dependent events (McDaniel and Driebe, 2001). In
addition, the system has encrypted memory which is expressed with predisposition. This is another
hidden ingredient of the healthcare system. Predisposition is a key factor either in enabling or
inhibiting certain patterns of behaviour. The path through which agents have unfolded their
capabilities to learn and act trying to co-evolve with the system creates a historical framework. This
is history for the system and is useful for the newer agents to retrieve models of action and thinking
ways. Nevertheless, knowing whether to stand on the remembering or forgetting side of history is a
talent which could be proved saving in dealing with complexity.
Predicting the future is uncommon and cause-effect relationships are no longer in the centre of
coping strategies. In thinking about the future, scenario planning still may help a system to deal
with uncertainty but not with unknowability. In the first case, possible scenarios are given and there
is uncertainty in terms of which will emerge while in the second case, there is no ability to define
scenarios. In complexity, such cases could be confronted through bricolage. Begun et al (2003)
defined as bricolage: the ability to make creative and resourceful use of whatever materials are at
hand, regardless of their original purpose. This hides the ability to create positive outcomes from
what emerges, through confusing and mixed-up situations. In other words, this means to create
something out of nothing (Zimmerman et al, 1998). Healthcare system is a complex system of
interconnections which accommodates social processes which in extent shape a significant part of
its own environment.
Thinking about the future in complexity presupposes learning to deal with surprise. However,
surprise drives evolution such as utopia motivates creation. Therefore, working with ambiguity in a
system with the characteristics that discussed in previous sections, cannot be productive unless
there is knowledge capacity, and innovation. Acute occasions demand analogical responses.
Dealing with surprise requires improvisational behaviour. In complex adaptive systems loose-tight
coupling is an attribute experienced many times. Traditional ways of reaction are not enough, as
they need to be supplemented through intuition guiding actions. Agents could build a basic form of
action using their instinct, knowledge, skills and risk. This is necessary especially in chaos-order-
chaos phases. Action could focus in small inputs which always provide room for learning and
development. In healthcare the essence of the system nests in relationships not in pieces,
therefore quality of connections is important. Especially in healthcare complexity means
interdependencies and the range of agents’ influences. Taking action presupposes to find ways in:
revealing new agents, unleashing hidden powers and creating the conditions for new structures.
The widening of systems’ actors is expected to resolve healthcare issues.
It is agreed that CAS cannot be controlled but there is a dynamic to administer effectively the
predetermined complexity space; to achieve that, there is a need to develop a stable cognitive
process. This is called mindfulness (McDaniel and Driebe, 2001). It is the capacity to induce a rich
awareness of discriminatory detail and a capacity for action. It is necessary to apply continuously a
set of processes as given in Figure 15 which are supported by the acceptance that survival means
a struggle for alertness.
Figure 15. The processes for developing mindfulness

• Preoccupation with failure
• Reluctance to simplify interpretations
• Sensitivity to operations
• Commitment to resilience
• Under‐specification of structures

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Attention is another function, as important as, information in CAS. Healthcare systems do not
stand in one-world but in a matrix of co-evolving worlds within which they must function. These
processes are key practices where the mindset is the heart and observation is the blood for the
system to survive. The observation should be done from the inside perspective, as agents of the
system and not as external observers. Observation remains in the centre of behavioural patterns
and is the essential component of the future non-linear interactions causing emergent behaviours.
In the next figure (Figure 16), there is an attempt to represent what have been discussed so far
in the section; these are the strategic components, necessary to let complexity to work.
Figure 16. Putting Complexity to Work (strategic components)
Such components form a strategy in dealing with surprise and unknowability. Their presence is
imperative. Lack in any of them diminishes the power of agents to affect the evolvement of the
complex system.
4.6 Conclusions and link with the study
The characteristics of Greek recession were rather the mirror of its internal paradoxes. Greece
is still considered a unique case since it is the first EU country which suffers such consequences
although it is part of a strong group. Its economic history proved that the problems raised were not
new. However, the country was always receiving external help in similar occasions in the past, but
now the time changed and new powers have been emerged in global terrain.
Global rules and geopolitical relations are complex and cannot be confronted with old traditions.
Economic recession affected healthcare sector and provoked a series of changes that are still

29

under construction. Society is still in shock and different groups are left in their own perceptions
about the possible futures. The old-mechanistic view of thinking and acting is obsolete. Modern
literature has proven that a more holistic view is necessary to be adopted and a different mindset to
be diffused into locals.
Complexity and complex adaptive systems are already part of daily routine and the study on
their characteristics is more important prior to any plan. The examination on mechanisms that
affect behaviours (attractors), the groups (agents), the new and different members (emergent
dynamics and diversity), the ways that healthcare people co-exist and co-evolve, are some of the
objects of this work. There are ways to embrace complexity and enable a system to survive and
succeed.
Current study aims to realise what is the perception among healthcare groups in terms of
complexity and future outcomes, given the case of restructuring and changes imposed. It is
important to identify, at least from the selected sample where the sector stands. This does not
necessarily imply that we have identified a literature gap rather than a practical representation of
living experience among peers.

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5. Methodology
5.1 Introduction
The examination of current subject demonstrates difficulties; embedding healthcare service in a
complexity context is considered a challenging case to analyse; therefore it was decided to apply
an exploratory humanistic research. In this chapter is discussed the approach that we have applied
(section 5.2), the data collection method and instrument (section 5.3), the sampling (section 5.4)
and the data analysis (section 5.5).
Examining perceptions and analysing experiences of participants incorporates dilemmas in the
translation of meanings.
5.2 Approach
The study followed a qualitative analysis. Besides, there were various quantitative approaches
that already have demonstrated important results on aspects of the sector. Also, healthcare sector,
as discussed earlier, is under tight control which is stemmed from health economics issues.
It was our intention to investigate the human experience as it is lived, felt, undergone and
experienced by its actors. This implies the attempt for searching contents and patterns that current
situation raises and provides ideas for further research. The approach is exploratory and
humanistic. Healthcare complexity accommodates strong relationships and a reality which is
constructed by its participants. Therefore, the challenge for this study was to generate text in
grabbing patterns and perceptions from participants through collection process. This is mainly a
process which focuses on aspects of human activity. The strategy was to observe and discuss
healthcare complexity as a social phenomenon and consider its people as part of this social
context.
5.3 Data Collection
The research instrument for the study was the semi-structured interview questionnaire with
open-ended questions aiming to stimulate further discussion and reveal information sourced from
participants’ expertise and daily practice.
The initial questionnaire was in English language (Appendix I.1). However, since the survey was
focused in the Greek case, and the target group was people who worked in healthcare sector, it
was considered necessary to produce an additional questionnaire in Greek language (Appendix
I.2). Another reason was that initial questions were too scientific in English language, as the
questionnaire accommodated complexity’s terminology which could be difficult for the respondents
to understand easily. The questionnaire in Greek language was edited under a simplistic approach
trying not to change meanings. So, respondents had access to both. It was crucial to secure that
respondents should have a clear understanding of what was going to be discussed. The translation
of meanings and comments during data registration was done by the author of the study.
Interview is the most suitable method of data collection, especially when the focus of the
research is to generate qualitative data (Whiting, 2008). The bottom line in interview is reflexivity,
which in the case of healthcare research may be proved valuable. Reflexivity could be applied
during the whole process of data collection, since this will enable values, assumptions, and
prejudices and influences to be acknowledged. To help this process, we have built interview
questions as playing cards trying to stimulate interaction for discussion. Nevertheless, these were
not used, as it was primarily planned, but may help in future research as an additional tool
(Appendix I.3).
The rich framework of literature as discussed in the study demanded a more challenging
interview type to be followed since the aim was to reveal the insights of healthcare experts.
Therefore, it was necessary to establish a two-way communication with interviewees and secure a
convenient environment where they would feel comfortable to discuss and share their opinions,
thoughts and knowledge. This interaction fit to semi-structured type of interview (DiCicco and
Crabtree, 2006). Although this follows a predetermined path, semi-structured interview
demonstrates loose structure of open-ended questions, which aim to explore the area rather than
get specific data. This method has the pitfall of not reaching a clear conclusion, if emerging insights
are not recognised properly. For this reason, the key function was to identify concepts and
variables that would emerge as different from what have been predicted (Britten, 1995). Questions
intended to be clear, sensitive and neutral. They were based on: (a) behaviour or experience, (b)

31

opinion or value, (c) feeling, (d) knowledge, (e) sensory experience, and (f) background details, of
the interviewee (Britten, 1995).
Initially it was scheduled to take 5 to 10 personal interviews, from professionals in healthcare
sector. The interview included 20 open-ended questions which were based on research objectives
and research questions’ framework as presented in the beginning of this study. Baker and Edwards
(2012) in their research about how many qualitative interviews are enough, they have tried to
identify the figure asking a significant number of experts. This varies on the nature of research, in
terms of what this intends to reveal.
The process included the options of either personal interview or the respondents to download
and fill the interview questionnaire. The second option proved more convenient, since it enabled
them to thing, reply and raise further issues for consideration. Many of them got back for
reconsideration after first thoughts. The estimated necessary time was 30-50 minutes.
Participants had the opportunity to visit in prior, the personal webpage of the author, where both
questionnaires (English & Greek versions) were uploaded for helping respondents in getting an
idea. The data collection process lasted almost three months.
5.4 Sampling
Regarding the sampling process, based on the research objectives, it was recognised that this
subject demands a different approach due to the specialties of the sector. The initial aim, in regards
to selection of interviewees, was to include in the study the opinion of various experts from
healthcare sector, and from different perspectives, specifically: (a) the medical, (b) the operational,
(c) the market, and (c) the government perspective. Therefore, the focus was to include
respondents from the following areas (Table 1):
• Government Officials (national, sub-national, local) (GOVERNMENT)
• Medical staff (doctors, nursing staff) (MEDICAL)
• Technical professional staff (paramedical, lab assistants)
(OPERATIONAL)
• Administration and supportive professions (OPERATIONAL)
• Pharmaceutical companies, pharmacists, medical equipment
companies (MARKET)
Table 1. Sampling categories
The initial target was to achieve the participation of two experts from each area in order to reach
the maximum of 10 personal interviews, as mentioned earlier. Finally the number of respondents
was 37 professionals. People in the sector seemed willing to participate in the survey, in general,
except of little cases that denied. The final sample covers four of the five areas. We could not reach
governmental staff. Respondents come from hospitals, both private and public, and the market.
Moreover, sample demonstrates big diversity since it includes people from various areas of
expertise in the sector (doctors, nursing staff, administration, technical and supportive staff,
pharmacists, medical companies etc.). Sampling was convenient and judgmental.
5.5 Data Analysis
Interview questionnaires with open-ended questions demonstrate specialties and difficulties in
terms of interpretation and extraction of results. In general, qualitative data analysis lacks of
specificity while sometimes the collected data give the sense of irrelevancy. On the other side,
such information is rich and is considered crucial when there is a necessity to examine social
context. Healthcare states at the base of governance for a society, thus studying a natural
environment, especially when this incorporates service experience, may be proved useful. The
sector is requested to cope with radical changes under extreme crisis situations. Therefore, instead
of quantifying - and taking into consideration the complex characteristics of the sector, as
discussed earlier – it was our attempt to apply a humanistic exploratory approach. We consider that
experiences cannot be treated similarly, although they could be matched in patterns for the benefit
of the study.

32

According to Polit and Hungler (1991), qualitative research is based on the premise that gaining
knowledge about humans is impossible without describing human experience as it is lived and as it
is defined. Besides, in align to the research framework of the study, reality is constructed by
participants (agents) while reality and social relationships need to be explained by the actual
participants (interdependencies, attractor patterns, heterogeneity, reflexivity, information
asymmetry). Therefore, data analysis is focused in meanings rather than measurements, although
there is an attempt to give a quantitative concern, to enrich the presented findings.
Data analysis remained orientated to coding as this is considered the most significant element
of qualitative approach. The method of interview followed enabled the researcher to improve it,
while being in the process of research. In addition analysis started immediately and progressed
incrementally, and provisional concepts were created. Important findings were easily matched with
research objectives and this was proved a strong testing of research’s progress in general.
Regarding coding, it was selected the thematic-content analysis. This type of analysis examines
recording patters (pattern-matching) in an attempt to categorize, compile and organize
interviewees’ personal opinion and experience. Lincoln and Guba (1985) raised four variables to
exist in order for a study to have quality in its qualitative research: (a) credibility, (b) transferability,
(c) dependability and (d) confirmability. All of them have a common characteristic. They try to
protect the objectivity of data and the study in extent. Moreover, thematic analysis has a key
process which is data familiarization. This process prerequisites the researcher to be familiar and
to do in person the whole research. Both factors have been accomplished in current study. It could
not be done otherwise, since interviews offers progressive modifications in the light of knowledge
and ideas. In addition, due to that data were contradictory and respondents have different opinions,
content analysis was the method which helped in interpretations of conflicting opinions (Graneheim
and Lundman, 2003).
Brown and Clarke (2006) defined as a theme the capture of something important in the data in
relation to the research questions which represents some level of patterned response or meaning
within the data set.
In order to secure the coding process, it was considered useful to perform interview results’
taxonomy (thematic analysis taxonomy-Appendix M), as a mean to identify and capture themes.
Such technique enabled the study to categorize and unitize data. Then, it was easier to apply
matching and comparison, in an effort to find variations or identify themes. This process operated
towards research questions within research framework as this was initially decided. The
identification and discussion on themes was the mediator to reach answers.
In Appendix M is given the registration of raw data from each interview, being translated from
the original Greek language, as interviews took place in Greek language. In continuous, these data
were categorized according to the 6 groups of research questions’ framework. In Appendices N1 to
N6 are given the tables which were produced for each research category. Taxonomy helped the
survey in the parts of content analysis and patterning.

33

6. Ethics and Ethical duties
Ethical issues were a priority for this study. Since interviews intended to bring forth and discuss
a series of thoughts, objections, inside information etc., of participants, the study focused on: (a)
confidentiality and (b) respect for the potential vulnerability as may be derived through the
interactive process. This means that interviewees’ opinions will not be exploited for personal gain.
Protection of study’s participants’ remains in the centre of ethical duties, and this is reflected
practically through anonymity, privacy and destruction of data, upon publication of this study.
Moreover, they were provided in prior with adequate information about the nature of the study. The
expectation was to ensure effective communication on the intent of the investigation.

34

7. Findings & Discussion
The experience of collecting information from different groups of the same sector was essential
and constructive. Moreover this was significant since nowadays, the sector is placed in the centre
of turbulence having to confront with radical restructures while being in the transitional stage of
self-evaluation and reposition.
Data analysis followed the research questions’ framework, as this could be helpful for the
discussion on findings and any future suggestions.
7.1 Information Asymmetry
From data analysis it was extracted that not all participative groups have the same accessibility
and power over information in healthcare sector. This means that some agents have more power to
administer and manipulate the end service offered. This is called information asymmetry. And this
exists in the sector according to responses. In the era, where information is capitalized and is
object of trading, it is imperative to examine this characteristic in healthcare system of the country,
trying to assess respondents’ views and perceptions. According to a respondent “all involved
groups have same kind of inside information” while another declared that “doctors and
pharmaceutical companies have inside information since they both form it”.
Adopting a more strict and commercial attitude, in information asymmetry, there was an effort to
identify who is the boss in the system. Which is the dominant group and who is the attractor that
remains in the centre gaining power and affecting any progress? Through the process of
identifying, prioritizing and revealing, we have concluded in the strong agent-based nature of the
Greek healthcare system, which in current situation is unbalanced, since there is one dominant
group. Prior to this conclusion, respondents have identified a remarkable number of participants as
agents in the complex healthcare system. Below is given the table (Table 2) including the agents
(groups) in the sequence of the more often appeared in data analysis (a top-down approach where
the more discussed is at the top).
Groups in Greek healthcare system
1. Doctors (University, Clinical, Private, Hospital, Insurance).
2. Nursing staff.
3. Administration and Administrative staff specifying Hospitals
administration, Presidents and Councils of Hospitals as well as
Public Insurance Organizations.
4. Pharmaceutical companies and the network of distributors,
wholesales (medical and pharmaceutical products).
5. Pharmacists.
6. Paramedical staff (first aid staff, lab assistants, and other supportive
specialties, therapists).
7. Other administrative supportive staff such as: cleaning services,
cooking, safety and security, technicians.
8. Other health supplementary specialties such as social and health
workers, and similar professions who work in the system.
9. Ministry of Health.
10. Government, governmental legislators and political parties.
11. Unions & professional associations.
12. Patients.
13. National Organization of Medicines (EOF)
Table 2. The Groups in Greek healthcare system
The above table reveals how the respondents perceive the sense of participating in the system.
Although the data came from diverse groups, it is worthy to mention that awareness of State’s
penetration in the sector remains low in people’s mind. Healthcare system in Greece means
primarily medical groups. Possibly this is because through time, only these people were the ones
who undertook full responsibility for any progress. Another significant point is that unions stay low

35

in the list, although there is a strong attitude towards unionization among professionals.
Perceptions and views are varied regarding the cost-benefit relationship of unions’ existence, and
whether these finally helped the sector.
The views on prioritization of powers did not surprise. This is clearly a doctor-centered
healthcare system where other groups position themselves depending on their relation and
connectedness with them. It is interesting that the survey raised the issue of “different” doctors,
implying the subgroups of doctors and the corresponded powers they can exercise over system.
There was an effort to place hospital doctors higher in internal hierarchy than others. Nevertheless,
this is a slightly blurred zone, since common practice in Greece reveals that doctors may have
multiple roles. This is how operates the ethical climate, which is a strong characteristic of
complexity in the sector.
Obviously, such multitask-orientated environment, positions them in a unique and distinct place
in healthcare. Below is given the table which gives the prioritization of groups, in the row of power,
as extracted by respondents’ opinions.
Prioritization of groups in terms of role and power in Greek
healthcare system
1. Doctors (including all subgroups giving the fact that in practice
they may be part of different subgroups at the same time).
2. Nursing staff.
3. The building block of pharmacists and pharmaceutical
companies - pharmaceutical distributors (wholesale &
warehouses of medical and pharmaceutical products).
4. The administration of Hospitals and people in administrative
posts in general.
5. Ministry of Health, Government, European Union directives,
Politicians and Political Parties.
Table 3. The most powerful groups in Greek healthcare system
Nursing staff is considered a significant group in the sector. Being the direct co-operator of
doctors and staying in the middle between them and other groups, it demonstrates a significant
proximity to decision making centers. This is probably due to the nature and role of their job
description. In other words, they are the operations department, undertaking various
responsibilities, accomplishing difficult tasks on daily basis and many times are obliged to
administer difficult situations. As a result, they develop problem solving and negotiation skills. They
have both medical and managerial role which from time to time unavoidably raises contradictions.
Discussion on this issue with respondents undermined the contribution of unions as a different
power-group.
Healthcare people claim that unions, by themselves, do not form power groups. These exist
supplementary. The above five groups are considered the major players in the system. Strange
though that governmental power is considered low again. Taking into consideration current case of
restructure in the country, it is weird to expect that the 5th
powerful group will prevail and impose
changes that are top-down driven. Beyond practical terms, the country, as discussed in literature, is
experiencing a major restructure therefore building blocks, information and relations are expected
to play primary role in the upcoming new structures.
From data analysis it is extracted that the first three groups create a monopolistic structure in
terms of information administration in the sector. Information is diffused and shared through certain
channels in a way that there are asymmetries. At this stage, some respondents were not clear or
have a clear view whether these are monopolistic phenomena. However, the existence of
monopolistic situations is not necessarily a result of imposition. There are various parameters that
could enable or discourage them.

36

Respondents agreed that more use of technology will help, but they were not certain about the
format of the new information framework. Although it was identified the doctors’ privileged
accessibility in building information, it was well admitted that they distribute their findings in
cooperation with various and different networks.
Furthermore, monopolistic situations are identified in other sectors as well, where the closer you
are in decision making centers the more inside information you acquire. The degree of technology
acquisition and its effective adoption defines either the release or restrain of information to all
involved parts.
Information asymmetry exists wherever and whenever technology suffers from paradoxes and
paternalistic models (“I protect you-You protect me” attitude).
7.2 Relations and Interdependencies
Healthcare sector, due to its nature and significance for the society, provides a fertile ground for
the development of relations and interdependencies, which is rather more intense comparing to
other sectors.
It is not accidental that powerful groups emerge from relationships’ networks. In complex
systems dominant groups are the ones which definitely have succeeded in creating and preserving
mutual benefited relations in strategic and visionary ways. Such relationships are not necessarily
negative for the system. They do play significant role in system’s evolution and they do give certain
characteristics, when we are trying to examine them holistically. It seems that Greek healthcare
system is rather built on relations and interdependencies and not on clear organizational contexts.
All respondents highlighted undoubtedly that relations do exist among groups and they do affect
them. According to one of them “since the staff is obliged to cooperate and interact, it is inevitable
not to exist relationships”. More respondents declared that these are important and necessary for
the progress of the system. Besides, in a human social system, to work, there must be a framework
of relations and a social coding. Nevertheless, these relations become interrelations and in extend
interdependencies. Medical staff demonstrates close binds to pharmaceutical companies due to
their common ground in terms of prescribing medicines to patients and doing research.
Pharmacists experience same direct binds with pharmaceutical companies. Doctors work closer to
nursing staff and this, by itself, creates stronger affiliations. On the other side, in general terms,
such binds could be found in other professions and sectors as well.
However, these relations are very important among agents as long as these are acting for the
benefit of the sector, ensuring consensus towards certain targets. On the other hand, relationships
direct to stratification of groups and people. This introduces a leader-follower model which under
various circumstances resulted negatively for Greece. In this situation, the weaker groups having
accepted that they are in backseat were waiting for things to change.
But, these relations helped in a way the knowledge progress and assimilation among groups no
matter if this sounds odd. For example doctors having the financial support of pharmaceuticals
developed research and produced high achievements. Consequently, the progress was rather
distorted but with significant achievements as well. Not socially-orientated but science and medical-
centered. This is like when focusing on targets, there is an increasing possibility of missing
essential characteristics that are fundamental for the survival, even if you reach your targets.
Relations patterns are defined by the system. May be the groups that are responsible for
relationships and prospective interdependencies but the system itself, defines the frames and the
limits. Almost all respondents, being originated from diverse groups, have concluded that reference
point is: the system. But who comprise the system. When the system is medical-centered,
obviously dominant groups acquire the power to manipulate and apply accordingly relations
patterns. A group-centered approach helps castes, and privileged members-leaders to reproduce
specific models and restrain hidden powers keeping the system in hibernation. This has a rational
and is not surprising. Dominancy and patriarchy was a usual combination of managing
communities through time. This appeared as a natural tension in humanistic evolution. Such
approach establishes mechanisms and norms trying to penetrate and embed its perceptions to
group members. Respondents declared that the Greek healthcare system is organized in a
paradoxical way which enables distortions and reveals weaknesses. Relations may create
interdependencies, but what happens in the occasion of unbalanced relations. Therefore, this set of
distorted principles when diffused all over the system, brings forth unproductive dependencies and
unfair equivalences among members and groups.
Changes in relations patterns could enable changes in the system and vice versa. At this case,
interdependencies play ultimate role in terms of how and how much emergence and self

37

organization will progress. Moreover, interdependencies affect any new powers and the level that
these will be unleashed or not. New technologies, in general, may play an additional role in this
framework. At least, this is what was discussed with some respondents. We could recall the
significance of Communities of Practice and how these merge and accommodate different powers
in an organization.
However, there is a perception that interdependencies serve only internal purposes, due to
mentality, therefore, their existence restrain any emergence of new structures. There is an
exception though in the case that this is the will of the system. This needs the cooperation among
groups, the exchange of ideas, the common perspectives and the willingness to succeed. In
addition, agents must be sure that there is benefit for them. An interesting view, extracted from
interviews was that distorted relations direct to distorted interdependencies, where obviously any
expectations are bind to close control and blocking. Usually such groups or systems are reluctant
to any progress preferring to maintain low intelligence and restrained knowledge among members.
7.3 Heterogeneity and diversity
Groups that operate in a complex system, although, they have common characteristics and
same objectives, they do demonstrate high degree of difference.
It is interesting that most of respondents kept a neutral or slightly negative attitude, in terms of the
role of diversity in the system. “Diversity could be a source of development” versus “diversity is
more of a source of problems”, as extracted from data. There was identified a small difficulty in
understanding the meaning of heterogeneity. According to them, heterogeneity is synonymous to
differentiation. Specifically, different groups in the sector demonstrate different approaches, where
sometimes this is the main cause for the deviation from the common targets, as it was discussed.
This differentiation is rather wide. In general terms, heterogeneity directs to different targets for
each group in the sector. Moreover, heterogeneity states in differences among groups that could
be found in knowledge, expertise, tasks and the nature of job itself, also rewarding, and personal
interests.
In addition, it was identified that the sector is consisted of different groups that do not
necessarily have common ground for cooperation. For example, any difference in aims, roles,
motives and attitudes raise different responsibilities and in result different behavior.
In other words, this kind of diversity was rather harmful and not helpful for the sector. The system
proved unable to handle heterogeneity or diversity in the sense that this was perceived by
participants.
This differentiation was obvious and easily found in the workplace, especially in hospitals and
public healthcare service areas. Specifically, the area of medical doctors and nursing staff is such
an example. Diversity is considered as the origin of communication problems and difficulties in
understanding. This becomes more intense when one group cannot understand the problems of
the other.
As a result, in a complex system this raises weaknesses and possibly isolates groups in a way
that they stop seeing the whole and the benefits of being together. It is difficult to integrate a mix of
powers under a common target, especially when enough groups consider, a priori, that this is
impossible. Interviews have revealed that a significant number of participants do not consider
heterogeneity as a source of development. Furthermore, some consider it as source of problems
and potential tensions. In the case of identifying it as a source of development, the respondents
placed some prerequisites implying that there always must be present some factors.
7.4 Attractor and Attractor patterns
Groups that live in the healthcare system demonstrate special behavioral characteristics as well
as diversified reactions according to patterns. This refers to any changes that might arise. Such
patterns are cultivated through time and under circumstances from dominant groups. It is
interesting that each group that participated in this survey does not consider itself as an attractor.
There is a contradiction on perceptions regarding who is the attractor that establishes patterns in
the sector. As potential attractors may be considered the powerful groups that mentioned earlier,
such as doctors, nursing staff, the Government, the unions. In terms of patterns definition, on the
one side it was mentioned that this follows the Law framework and the Professional Code of Ethics,
as introduced by the State.
On the other side, though, there is a stubborn, informal framework which nurtures a parallel
entity with its own informal patterns and mindset. Therefore, different attractor patterns are

38

generated over the system’s weaknesses. Lack of: control, measurements, indexes, objectives and
specific guidelines, usually direct a system to self-correction in a way that it is not always desirable.
Giving the fact that attractor patterns define behavioral models and cultivate mindsets, it is clearly
understood that their role is more than significant in the system. The practice of affecting patterns
directs in affecting behaviors which in extent defines how absorbent and receptive the system in
changes is. Any monopolistic attitudes and restrained concerns create an aversive environment
which blocks change of structures. In order for the dominant players to maintain current structures
they impose contexts that operate positively for their benefit but disregard any upcoming
challenges, keeping the system rather closed.
Nevertheless, a system cannot survive without attractors. Therefore, the question raised is,
what we can do when current attractors do not serve anymore common targets but harm the
system. At this point, respondents were in the middle. There is a number claimed that a system
could not be rebuilt from scratch therefore it is necessary to use the old powers and help new
powers to re-establish the system in a new self-organizing way. It is impossible to destroy a system
and build it again, especially when this is the healthcare system of the country. The restructure
comes from a blended approach where old and new mix-up towards adaptation. This approach
mostly fits to the incremental progress, a natural evolvement of things under certain circumstances
where entities know well the environment and prediction could stand adequately for the things
ahead.
But what happens, when a complex system experiences sudden shocks and surprises, which
impose radical changes. Almost half of the respondents concluded that a new system should be
rebuilt from zero. This is a totally radical approach, where the system is expected to bring forth new
attractors in order to gain new perspective and change mentality and lifestyle. If you keep old
powers, it is not definite that the new system will not end in the same path. Therefore, we have to
choose between: (a) a transitional period where old and new will mix and progress, or (b) a stage
of new foundations, where the old system will be destroyed and new structures will emerge under
new formations and players.
The more realistic solution depends on the current situation of the complex system, as well as
the pressures that this experiences both internally and externally.
7.5 Generative relationships and patterns of behavior
The special characteristics that prevail in healthcare sector, in regards to behavior, reaction and
coping with change are stemmed also from generative relationships which are nothing more than
the common root relations. Such relationships are built-in the healthcare components, and play an
important role in the sector’s evolvement. May be these are the stronger type of relationships within
the system. Respondents accepted that such kind of relationships, although could be found
elsewhere, in healthcare are wider, stronger and intensive. They operate on the basis of protection
and solidarity among groups even if this demonstrates distortions. Additionally, they are based on
the instinct of self-preservation enabling the reaction of inter-coverage and mutual help. Probably in
healthcare generative relationships are more discrete.
As a result, they are embedding new contexts to members. Although they cannot impose new
structures or direct rules, they imply and prepare the ground for further informal changes. Various
results could be seen, such as cultivation of common interests or oppositions. Nevertheless, some
of the respondents mentioned that generative relationships cannot impose new contexts especially
when mentalities are offended or personal belongings and acquirements are jeopardized. There is
always the red line of humanistic protection in any rule, no matter which group prevails.
Behavioral models that stem from these relationships play a significant role in any will for
change since people define the system. So, although they cannot impose, they can both fight or
enable changes towards self-organization. It is the informal relations and the uncontrolled
principles that define the pathway for the change. Furthermore, closed relations damage the
system and many times formal hierarchy is not considered so significant and decisive for future
actions. Moreover, closed relations create problems, in terms of mechanisms of obstacles which
operate in contrast to official rules and control. In the Greek healthcare sector, generative
relationships and patterns of behavior are strictly connected and constitute the what-so-called
“status-quo”. This is responsible for the malfunctions in the system but it seemed that this was
widely accepted. Through another perspective, aspirations of participants are not always the same.

39

7.6 Collective Reflexivity
Groups of the system demonstrate a common reaction against anything that originates from
external factors. This happens also in the case that internal factors seem to unsettle the cyclicality
of the system. In any of these, the system stimulates reactions as an unconscious and natural
reflection. Reflection is linked to complexity since it is a common action observed in a system with
living entities. It is interesting though, what respondents perceived as group reaction. Collective
reflexivity is synonymous to fight and to opposition. It figures the way that different groups react
against certain attacks on their interests, acquisitions and rights. Agents start feeling the pressure
of change and external imposition, especially when these demand from them to change their work
and behavioral patterns. As a result, agents demonstrate a homogenized negative reaction.
This reaction is mainly cultivated by dominant groups. There is an opinion that reflexivity is
supported by the system and its endurance. However, as responsible for collective reflexivity, not
effectively always, were recognized the unions, the political parties and the government. These
groups have cultivated an environment of inertness in terms of positive reflexivity. Positive
reflexivity is the preparation and alertness towards changes. On the contrary, negative reflexivity
destroyed the good parts of the system through the years and developed a mindset of risk aversion
and change resistance. Although there was always the potential emergence of new powers, these
were restrained and kept away from decision-making centers.
7.7 Elements from NHS (The National Healthcare System of UK)
It is not accidental that UK’s healthcare system is considered one of the most modern especially
in terms of programming and organization. Although it has its own vulnerabilities, there are certain
guiding principles and governance issues that define the operating framework.
This system is based in two primary entities which set policies.
1. Primary Care Trusts, Accountants
2. GPs, Doctors, Directors of Clinics and Consultants
The accountants are the mediators between Ministry of Health and Hospitals. There is no
privileged accessibility from doctors or even pharmaceutical companies. Participants in the system
have direct cooperation with Primary Care Trusts who define and negotiate based on KPIs and
financial policies. Government is doing budgeting and define the strategy. Strategies are developed
taking into consideration two factors: (a) demographics, and (b) finances. Different opinions as well
as any kind of pressure against the system are expressed through Pressure Groups, which usually
are consisted of General Practitioners (GPs), Nursing staff and Patients. Another significant group
in the system is Research Groups of Hospitals. Relationships are mostly embedded among people
of the same group and it is difficult to find this across different groups.
There is a strong competition among Research Groups in terms of better research results,
better achievements and progress as this will enable them to look for more funds. Any conflicts lay
rather in motives of competition and not protectionism.
Planning is strict and implementation is close monitored in regards to policies and budgeting.
Healthcare sector accommodates experts and technocrats who undertake the responsibility to
accomplish operations in alignment to predetermined targets.
It was considered significant to include in this study some information from a foreign healthcare
system, such the one of UKs which is considered a model system. Dr Polychronakis (2013),
through his expertise in healthcare systems, have contributed in current study, giving the
perspective of another system. This was considered helpful in the attempt to bring in this study a
different approach and raise milestones towards changes that could take place in the Greek
system. In the next figure (Figure 17) is given the structure of NHS which combined with the later
provided Figure 18, provide a graphical representation of NHS.

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e MBA
e system.
mindset.
ke flow of
ndling the
efined as

41

Figure 18. The context of Healthcare
(Source: Polychronakis, Y (2013) Healthcare Management, Lecture presentation in the Executive MBA
course, University of Sheffield International Faculty, CITY College, April 2013)
This three-pillar approach is a model which could help in the endeavours of local players who
wish to contribute towards the restructure of the system.

42

8. Conclusions of the study
8.1 Discussion on literature review
Greek healthcare system is currently looking for its stability. We conclude from the survey, that it
demonstrates characteristics of a natural system which incorporates different groups with powers,
links and concerns (doctors, nursing staff, administration, other groups etc), (Simmie and Martin
2010; Clark et al, 2010). Complexity was born from diversity (McDaniel and Driebe, 2001) but this
is not clear in the respondents’ perceptions. There is a significant number of respondents that
opposed to diversity existing in the sector, and they consider it a problem for the evolution of
healthcare. Unknowability is a problem for the professionals in the sector as well. However, groups
still cannot identify the powers that could be a source of novelty and invention. Anything different,
unlabeled and not-approved is considered a threat for the system. Co-evolution is more of a conflict
nature rather than the possible fertile landscape for workable solutions (McDaniel and Driebe,
2001). Connectedness is still paradoxical and openness is selective. Non-linearity is eliminated
through patterns of protection; therefore, we consider that any rebounds will delay.
Begun et al (2003) proved to be correct in terms that all these years the sector has
demonstrated bounded behaviour regardless the necessity for changes. Finally, the system
succeeded in maintaining certain attractors, in an attempt to minimise impacts from small changes.
Emergence was rather disappeared. Absence of changes brought absence of self-organisation
either bouncing-back or bouncing-beyond. So, the system forgot how to move on.
Respondents did not propose any specific alternatives besides that some of them prefer to keep
old powers while others seek for new determinants in the new framework. Probably this is the
result of the internalised simple rules that were in power all these years (Pisek et al, 2013). The
answer states in ethical climate (Mills et al, 2003). The Greek healthcare sector nurtured a system
that endangered the sector.
There is lack of consensus among peers and people are not certain, or convinced on any
potential future positive outcomes. There are contradictions while the sector experiences a self-
concern and a self-approval stage. The system is still vibrated from shocks and this is probably
going to last for quite few years. The duration depends on the effective absorption of these shocks
and the transformation to constructive results. However, this survey reveals that diversity will not be
integrated easily. Emergent dynamics delay and this delays the new organisation of the sector.
Furthermore, although this survey cannot generalise its findings, we could conclude that the
Greek system did not manage to penetrate in the DNA of complexity. On the contrary, it
experienced signs of uncertain autonomy. As a result, the adoption of mechanistic view of things
has made the sector even weaker in complexity’s characteristics. There are two ways to change
things: incrementally or radically; this means either naturally and controllable or suddenly with
violence. Decisions of a society define its path-dependence. If we multiply these decisions over
time, the position of the society is the result of its choices.
In times of prosperity, groups are reluctant to changes. The dominant perception is that you do
not change a team that wins. This, in extent cultivates a fake environment of endless security and
grows the mentality of “too big to fail”. However, in times of prosperity, societies could be entrapped
in inertia.
Restructures as imposed by memorandums should take place, and fast. Consequences were
and still are catastrophic, but this is the result for the societies that do not foresee changes and do
not adapt accordingly when resources are enough and available.
Beyond, re-organization of things and during the phase of changes (the phase of living the
crisis) certain practicalities should take place and these are:
• Clear orientation and plan of what the sector should achieve towards crisis; each unit
should make and apply immediately a contingency plan for its operation.
• Administration should be enriched with healthcare experts who will undertake the
responsibility to apply changes using more technology and enabling more groups in the
effort to build the new system.
• Healthy old powers could be used but only if they meet their job description
requirements. More managerial control should be assigned and the system could
incorporate modern techniques in terms of health economics, logistics and policies.
• New poles of power should be revealed in order to change balances towards a modern
healthcare framework for the country.

43

Fastness of changes depends on the participants. The Strategy Pyramid as introduced by the
author (Figure 15), is an example for further study. Real progress comes when restructures and
changes drive society towards a fair distribution of resources and wealth. This in extend implies a
fair and unhindered provision of healthcare services to citizens. It is still questionable though,
among many local players, whether the mechanistic metaphor stands below or above complexity.
In the doorstep of quantal complexity, the country is obliged to confront with inevitable
challenges. In response, putting complexity to work may prove to be wise choice. But this demands
consensus among social partners and this is questionable. It is hard to predict if Greek society hold
on the transitional stage towards new organisation of things.
Interfering in local economies through monetary policies is a productive and decisive strategy to
impose changes in rather short time. Resources and in extent money is the basic component for a
social system. Lack of resources seems that are not the permanent fear of managers but for
societies as well, especially nowadays where changes are happened through different ways. Being
in the fourth year of recession, it’s rather certain that the country experiences a dilemma.
Complexity demands holistic approach.
Another issue is that there is no replacement of generations in terms of changing patterns and
mindsets. Things are changing quickly and attitudes have to do the same. The prolongation of life
as well as modern lifestyles enables longer status-quo narrowing the potential for space for new
powers.
The map given below (Figure 18), is an attempt to illustrate the factors that define the
complexity space on healthcare. This examines healthcare through global lens.
Figure 19. Healthcare – The 7 Circles of Complexity Space (a global approach)

44

Circles of Complexity is an attempt to prove that no system could survive in isolation, neglecting
global environment and emergent powers that push towards renewal.
Greek healthcare sector as a complex adaptive system is rather obliged to move on fast and
recap things that had to do but did not succeed to, so far. No matter the external demands, this is
the way for the sector and the country to reposition itself, capitalise the experience and prepare for
the next challenges.
The system cannot oppose to current pressures. It does not have the resources and the
background. Moreover, as discussed through literature review, there is no way to administer
complexity. Past strategies that proved to be successful have been out-dated and changes that
were deliberately omitted all these years, reappeared.
Therefore, it is essential to perform changes using the good elements provided from the agent-
based nature, the connectedness and the new dynamics of the healthcare sector.
Greece had been trapped in a path-dependence that was organised and administered by old
powers, which had demonstrated certain distorted characteristics. Not only in healthcare but also in
other sectors, an ever-lasting-inertia created a pseudo-development. This is a situation which could
be reversed only through practicalities. And current crisis is an opportunity for this. Lack of
resources and tight controls enable improvisation, enrich mindsets and alter attitudes.
History has proven that changes happened all these years outside the country, had not been
diffused in order to stimulate the internal environment. Discussions about democracy and dead-
ends given current conditions are not realistic. Of course, there are dead-ends and the systems are
obliged to regenerate and renew themselves whenever this is imposed, either from internal or
external powers. Emergence of new dynamics should be considered as healthy sign of progress.
The dead-end in real, technocratic world is called: resources, which does not imply only materials
but the capacity to learn as well.
8.2 Implications
This study did not intend to extend beyond research objectives. The discussion on impacts and
outcomes are expected to contribute for future reference, further study and for any additional
consideration.
The case of Greece is unique globally, at least until current times where this paper is in process,
since there was no prior example of an advanced country belonging to a strong currency
consortium but demonstrating such economic indicators. The intention of the research was to
analyse, discuss and bring forth any issues related to health governance stemmed from the difficult
situation that country experiences.
However, it is expected to reveal chronic weaknesses of the sector, which actually illustrate the
willingness and motives of societal partners.
8.3 Limitations
The major limitation in this study is that findings could not be generalised since these are
considered biased due to the method followed. Nevertheless, intention was to study on experience
perceptions of respondents and capture a part of current implications in the sector.
In addition, regarding sampling, there were initial concerns on how to reach governmental
officers. This was proved difficult during the survey. Therefore, most of the respondents come from
medical group and from different posts and areas. We have tried to balance the absence of
governmental officers with variety of groups within sector. Nevertheless, this may raise a weakness
since there is no view included from the government’s side. Due to time restrictions, we did not
insist or go after any further opportunities.
8.4 Further research
The case of Greek healthcare sector could be a model case for further research, in terms of
how complexity applies in living systems which experiences shocks.
It would be interesting though if continue to study on the selected sample throughout the
different stages of crisis and restructuring, as we are experiencing it now. The aim should be to
analyse perceptions and study on their incremental or radical potential changes. Some proposed
questions for research are given below:

45

• Do modern times of crisis demonstrate different change characteristics across people,
compared to older periods?
• Does complexity affect the way people decide to change through time?
• Do finally, people learn how to learn during tough periods or prefer to remain in stasis?
• Is complexity a recent phenomenon or exists through ancient years playing always its role
at the background?
8.5 Contribution of the study
Initial motive of this study was to investigate complexity and identify the links with healthcare
sector given the Greek case. We have resulted in capturing current situation through examination
of healthcare sector’s professionals. Actually, the intention was to bring forth their perceptions
under shock conditions. We have tried to identify the consequences that turbulent situations raise
as well as any reactions towards this.
Our exploratory humanistic approach aimed to register the impact in healthcare from inside
information. This was performed in combination with the examining of the role of complexity in what
the country currently experiences.
Although our conclusions may not be used for general declarations, we consider that our
findings provide an evidence-based report that reflects the result of linking complexity and
healthcare in a modern developed society which did not follow holistic approach.

46

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51

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53

APPENDIX A
GREECE: GDP in the decade 1951-1961 (growth rates)
Comparison with other OECD countries
(Source: Bowles, Samuel (1966) Sources of growth in the Greek Economy, 1951-1961.
Harvard Economic Development Report, No. 27, p. 9).

54

APPENDIX B
GREECE: GDP in the decade 1951-1961
Distribution of growth rates per sector
(Source: Bowles, Samuel (1966) Sources of growth in the Greek Economy, 1951-1961.
Harvard Economic Development Report, No. 27, p. 10).

55

APPENDIX C
GREECE: Unemployment 1970-1993
(Source: Demekas, Dimitris and Kontolemis, Zenon (1997) Labour Market Performance and Institutions in
Greece. Journal of South European Society and Politics, 2(2), p. 79).

56

APPENDIX D
Directives in controlling pharmaceutical spending
(Structural fiscal reforms in Greece)
(Source: IMF-EU-ECB (2012) Memorandum of Understanding on Specific Economic Policy Conditionality,
p. 13).

57

APPENDIX E
Directives in adopting the use of generic medicines

58

p. 15-16).

59

APPENDIX F
Directives in pricing of medicines
p. 13).

60

APPENDIX G
Directives on prescribing and monitoring

61

p. 14-15).

62

Appendix H
Mapping the process of organizational learning from crisis
(Source: Elliott, D (2009) The Failure of Organizational Learning from Crisis – A Matter of Life and Death?
Journal of Contingencies and Crisis Management, 17(3), p. 159)

63

Appendix I.1
Semi-structured interview questionnaire
Discussing Complexity in the Greek Healthcare Sector
This paper can be used as a guide to perform the semi-structured interview with the participant
in the study. There are 20 questions grouped in 6 categories according to Research Questions
Framework.
1. Information Asymmetry
1.1 Who are the players/agents in healthcare?
1.2 Can we prioritize them according to their power in
regards to health services supply chain? Who are the
agents that play primary role?
1.3 Who has inside information due to current structure?
Can this change? What is necessary to do in order to
restrain information asymmetry?
2. Interdependencies
2.1 How important are the relations among agents in
healthcare? Do relations play a decisive role for the
system? Is this positive or negative or even neutral?
2.2 Who defines the relations patterns in the system?
Who is responsible for the relations; the system or the
building blocks of agents?
2.3 Do relations create interdependencies? Does this
create paradoxes in the system? Does this reveal
weaknesses?
2.4 What is the real nature of interdependencies? Do
they enable or block emergence and self-organisation?
3. Heterogeneity
3.1 What is heterogeneity in healthcare?
3.2 Where and how this is identified? What kind of
problems does this create?
3.3 Can heterogeneity be a source for development?

64

Discussing Complexity in the Greek Healthcare Sector
4. Attractor Patterns
4.1 What is an attractor pattern? Who is an attractor in
the current healthcare system in the country?
4.2 How these patterns work in the system? Do these
impose contexts? Is this possible for a new attractor to
emerge from changes in structures?
4.3 Can the system work without attractors? When
attractors take responsibility and protect the system?
5. Generative Relationships
Patterns of Behavior 5.1 What are the generative relationships and what is the
difference with relationships as discussed earlier?
5.2 Do generative relationships create contexts in the
system? Who is the main source of such relationships?
5.3 Do generative relationships have responsibility for
fighting or enabling changes in structures towards self
organization?
5.4 Which is the relation between generative
relationships and patterns of behavior? Can this
relationship be the cause of emergence?
6. Collective Reflexivity
6.1 What is collective reflexivity? What is the relation with
complexity?
6.2 Who is responsible for reflexivity? The system or the
agents?
6.3 How reflexivity works in healthcare sector?

65

Appendix I.2
Semi-structured interview questionnaire (in Greek language)

ΙΑΝΟΥΑΡΙΟΣ 2013

Η συγκεκριμένη έρευνα έχει ως στόχο να προσεγγίσει την τρέχουσα κατάσταση στον τομέα
υγείας της χώρας, κάτω από το πρίσμα της πολυπλοκότητας. Πραγματοποιείται στα πλαίσια της
μεταπτυχιακής εργασίας του κ. Ευάγγελου Εργέν, φοιτητή στο πρόγραμμα ΜΒΑ του
Πανεπιστημίου του Sheffield, UK που προσφέρεται στην Ελλάδα από το Διεθνές Τμήμα του
Πανεπιστημίου, CITY College. Η μεταπτυχιακή εργασία έχει τίτλο "Using Complexity as a guide for
acting in Healthcare" και όλα τα στάδια προόδου της θα δημοσιεύονται στην ιστοσελίδα
http://www.ergen.gr/HealthCare.html.

Η εργασία γίνεται υπό την επίβλεψη του Δρ Αλέξανδρου Ψυχογιού, Επίκουρου Καθηγητή του
Διεθνούς Τμήματος του Πανεπιστημίου του Sheffield.
(a.psychogios@city.academic.gr)

Ακολουθεί ένα ερωτηματολόγιο συνέντευξης με ανοικτές ερωτήσεις που απευθύνεται σε
συμμετέχοντες που έχουν επαγγελματική σχέση (ή είχαν σχέση) και δραστηριοποιούνται στον
τομέα της υγείας στην Ελλάδα.

Ο σκοπός είναι να συλλέξουμε και να επεξεργαστούμε απόψεις ειδικών τις οποίες θα
αναλύσουμε σε σχέση με την βιβλιογραφία αλλά και την πρακτική, όσο αναφορά την
πολυπλοκότητα. Αυτό στοχεύουμε να βοηθήσει στην κατανόηση εκείνων των χαρακτηριστικών
και ιδιαιτεροτήτων που παρουσιάζει το σύστημα υγείας της χώρας μας.

Η συμπλήρωση του ερωτηματολογίου (συνέντευξης) γίνεται κατόπιν πρόσκλησης που θα λάβουν
μέσω e‐mail οι συμμετέχοντες. Το κείμενο είναι σε μορφή επεξεργάσιμη προκειμένου οι
συμμετέχοντες να έχουν την ευελιξία να δώσουν τις απαντήσεις τους και να εισάγουν στην
συζήτηση και νέες πτυχές που πιθανόν κατά την άποψη τους δεν καλύπτονται.

Τα αποτελέσματα της έρευνας θα αναρτηθούν στην παραπάνω ιστοσελίδα, μέχρι το τέλος
Ιουνίου 2013. Η συμπλήρωση και η υποβολή του εν λόγω ερωτηματολογίου, χρονικά ορίζεται
έως και τις 15 Μαρτίου 2013. Η υποβολή γίνεται μέσω email στο ergen@ergen.gr


Σας ευχαριστώ πολύ για τον χρόνο σας αλλά και την διάθεση να συμβάλλεται στην συγκεκριμένη
έρευνα.

Με εκτίμηση
Ευάγγελος Εργέν
(ergen@ergen.gr)

Η πολυπλοκότητα στον
τομέα υγείας της Ελλάδας

66

ΑΝΟΙΚΤΕΣ ΕΡΩΤΗΣΕΙΣ (ΣΥΝΕΝΤΕΥΞΗΣ)

1.   Ποιές είναι οι ομάδες που απαρτίζουν το σύστημα υγείας της χώρας μας? (π.χ. γιατροί,
νοσηλευτές, φαρμακευτικές εταιρείες κλπ). Παρακαλώ καταγράψτε όσες ομάδες  νομίζετε
ότι συμμετέχουν.
2.   Μπορείτε να τις χωρίσετε σε κατηγορίες ανάλογα με την δυναμική τους στον κλάδο?
Ποιές/Ποιά είναι η ισχυρότερη/ες? Ποιές κατά την άποψη σας παίζουν πρωταρχικό ρόλο
στις τρέχουσες αλλαγές που πραγματοποιούνται στην χώρα?
3.   Ζούμε στην εποχή της πληροφορίας. Ποιά/Ποιές ομάδες πιστεύετε ότι διαμορφώνουν την
πληροφορία? Ποιά/Ποιές έχουν ενδεχομένως προνομιακή πρόσβαση? Υπάρχουν
μονοπωλιακά φαινόμενα στον κλάδο? Μπορεί η χρήση τεχνολογίας να βελτιώσει την
διαχείριση της πληροφόρησης για το καλό όλων?
4.   Υπάρχουν σχέσεις αλληλεξάρτησης μεταξύ ομάδων στον τομέα της υγείας στην χώρα μας?
Πόσο σημαντικές είναι αυτές και πόσο επηρεάζουν την λειτουργία της υγείας? Ανάλογες
σχέσεις μπορεί να συμβάλλουν θετικά ή αρνητικά σε οποιεσδήποτε εξελίξεις?
5.   Ποιός καθορίζει τις σχέσεις αλληλεξάρτησης? Κάποια ομάδα, συνδυασμός ομάδων, μήπως
το σύστημα το ίδιο λόγω της οργάνωσης του?
6.   Μπορεί μια σχέση αλληλεξάρτησης να δημιουργήσει παραδοξότητες ή να επιφέρει
στρεβλώσεις?
7.   Μπορούν αυτές οι σχέσεις να προκαλέσουν αλλαγές στο σύστημα? Μπορούν να βοηθήσουν
στην απελευθέρωση νέων υγιών δυνάμεων? Μπορούν να οδηγήσουν σε μια νέα αυτο‐
οργάνωση?
8.   Στο σύστημα υγείας συμμετέχουν διάφορες ομάδες? Υπάρχει διαφορετικότητα μεταξύ των
ομάδων, παρόλο τους κοινούς στόχους που ενδεχομένως έχουν? Εάν υπάρχει
διαφορετικότητα, πόσο ευρεία είναι αυτή?
9.    Σε ποιούς χώρους του τομέα, μπορούμε να διαπιστώσουμε εάν υπάρχει διαφορετικότητα?
Εάν τελικά υπάρχει διαφορετικότητα, αυτό αποτελεί πρόβλημα για την χώρα?
10.   Πιστεύετε ότι η διαφορετικότητα μπορεί να είναι πηγή εξέλιξης?
11.   Ποιοί καθορίζανε και καθορίζουν τα πρότυπα συμπεριφοράς μέσα στο σύστημα υγείας της
χώρας μας?
12.   Πως λειτούργησαν και λειτουργούν τα πρότυπα συμπεριφοράς όσο αναφορά την εξέλιξη
του συστήματος? Μπορούν τα πρότυπα συμπεριφοράς να αλλάξουν σε ένα νέο σύστημα
οργάνωσης?
13.   Θα μπορούσε ένα καινούριο σύστημα υγείας να προοδεύσει βασιζόμενο στις υπάρχουσες
και παλιές δυνάμεις του? Θα μπορούσε να αντέξει τις έντονες μεταβάσεις στην νέα αυτο‐
οργάνωση? Ή θα ήταν καλύτερο να διαλυθεί και να ξαναχτιστεί σε νέα θεμέλια?
14.   Εκτός από τις ευρύτερες σχέσεις αλληλεξάρτησης, υπάρχουν και ειδικότερες σχέσεις
προστασίας και αλληλοβοήθειας μεταξύ ομάδων μέσα στον τομέα υγείας. Αυτό είναι ένα
γενικευμένο φαινόμενο, ή αποτελεί ιδιαιτερότητα του συγκεκριμένου κλάδου?
15.   Μπορούν αυτές οι σχέσεις ιδιότυπης αλληλεγγύης να επιβάλλουν κανόνες στο σύστημα?
16.   Μπορούν αυτές οι σχέσεις να καθορίσουν νέες δομές και οργάνωση?
17. Προφανώς αναφερόμαστε στις κλειστές σχέσεις μεταξύ ομάδων συνήθως του ίδιου
επαγγέλματος ή ιδιότητας. Τελικά αυτό μπορεί να δημιουργήσει εμπόδια, σε ένα
πολύπλοκο σύστημα, όπως είναι η υγεία μιας χώρας?
18.   Τι θα χαρακτηρίζατε ως συλλογική αντίδραση? Υπάρχει σύνδεση μεταξύ αντίδρασης και
πολυπλοκότητας?
19.   Ποιοί μπορεί να καλλιεργούν την συλλογική αντίδραση? Μπορεί να είναι ομάδες? Μπορεί
να είναι το ίδιο το σύστημα? Μήπως συνδυασμός ή κάτι άλλο?
20.   Πως λειτούργησε και πως λειτουργεί η αντίδραση και τα αντανακλαστικά των ομάδων στον
τομέα υγείας όλα τα προηγούμενα χρόνια, μέχρι και σήμερα?

67

Appendix I.3
Semi-structured interview questionnaire (the playing cards version)

73

Appendix J
The study at a glance
(Structural mind-map of literature review
and main thoughts and findings)

74

Appendix K
Characteristics of Complex Adaptive Systems

75

Appendix L
Characteristics of
Complex Adaptive Systems
in Healthcare

76

Appendix M
Data Registration (translated raw data)

77

Appendix N
Data Categorisation
According to Research Questions’ Framework
1. Information Asymmetry
2. Interdependencies
3. Heterogeneity
4. Attractor Patterns
5. Generative Relationships
6. Collective Reflexivity

Interviewquestionnaire
(Englishversion)
Who are the players/agents in the Greek healthcare
system?
Can you prioritise them according to their power in
regards to healthcare services supply chain? Who are the
agents that play the primary role?
Who has inside information due to current structure? Can this
change? What is necessary to do in order to restrain information
asymmetry?
(Greekversion)
Ποιές είναι οι ομάδες που απαρτίζουν το σύστημα υγείας της
χώρας μας? (π.χ. γιατροί, νοσηλευτές, φαρμακευτικές εταιρείες
κλπ). Παρακαλώ καταγράψτε όσες ομάδες νομίζετε ότι
συμμετέχουν.
Μπορείτε να τις χωρίσετε σε κατηγορίες ανάλογα με την
δυναμική τους στον κλάδο? Ποιές/Ποιά είναι η
ισχυρότερη/ες? Ποιές κατά την άποψη σας παίζουν
πρωταρχικό ρόλο στις τρέχουσες αλλαγές που
πραγματοποιούνται στην χώρα?
Ζούμε στην εποχή της πληροφορίας. Ποιά/Ποιές ομάδες πιστεύετε ότι
διαμορφώνουν την πληροφορία? Ποιά/Ποιές έχουν ενδεχομένως
προνομιακή πρόσβαση? Υπάρχουν μονοπωλιακά φαινόμενα στον
κλάδο? Μπορεί η χρήση τεχνολογίας να βελτιώσει την διαχείριση της
πληροφόρησης για το καλό όλων?
1
Doctors, Nursing staff, Pharmacists, Pharmaceutical companies,
Paramedics.
1. Doctors, 2. Pharmacists, 3. Pharmaceutical companies and 4.
European Union Directives.
Information is formed by the above 3 first categories plus nursing staff.
Information is diffused in a monopolistic way and through definite
channels. Nevertheless more use of technology can affect and change
this phenomenon.
2
Medical Doctors, Nursing staff, Lab Doctors, Healthcare
Administrative Services, Paramedical staff, Supportive staff
(assistants, cleaning services, cooking services, safety and
technical support).
1. Healthcare Administration, 2. Doctors, 3. Nursing staff, 4. other
administrative supporting services (law services).
Information is formed by nursing staff, doctors and administratives in
healthcare. I cannot say if someone has specifically more inside
information, may be the administratives but it is not clear. There is not
monopolistic use in the sector though, but more technology definitely
is expected to help more the sector.
3
Doctors, administrative staff, nursing staff, technical and
support staff (e.g. Computer department).
1. Computer staff, 2. Doctors, 3. Nursing staff, 4. Administrative,
5. Technical staff.
People that have mainly access in information is the administrative
Computer people who have access in data and information. It is true
that such people have more and direct access. Nevertheless, i do not
know if this creates monopolistic status. The more use of technology
will make situations more controllable and sharing.
Thematic Analysis Taxonomy
Interviews' results on INFORMATION ASYMMETRY
Research Questions Framework
78

4 President of Hospital, Directors of Departments, Nursing staff,
Medical doctors, Paramedical staff, Administrative staff.
1. President of Hospital, 2. Director of Nursing staff, 3. President
of Union.
Technology can help in general terms, but can also create problems.
Information is provided by the Ministry of Health and its staff.
5 Doctors, Nursing staff, Therapists, other Health professionals,
Technical lab staff, Technical assistants, Administrative staff. 1. Doctors, 2. Nursing staff, 3. Administrative‐Technical staff.
All groups have inside information and define information in a sense,
but each group process the information owns seperately and
differently.
6 Doctors, pharmaceutical companies (medical and
pharmaceutical visitors salesmen), pharmacists. 1. Doctors, 2. Pharmacists.
The groups that are more familiar to technology are the younger
people, although the biggest market of healthcare is the older ones.
7
Doctors, nurses, pharmacists, technical staff, lab assistants. 1. Doctors, 2. Nursing staff.
Information is defined by all groups equally and all have access to it.
There are monopolistic phenomena but more technology can help in
balancing such occassions.
8
Doctors, dental doctors, nursing staff, other medical staff, social
workers.
1. Doctors who hold and administrative positions, 2. University
doctors, 3. Doctors, member in unions, 4. Doctors in
pharmaceutical companies, 5. Nursing staff.
Information is defined mainly by political staff and medical staff. The
increasing use of technology helps in the elimination of monopolistic
situations. The management of information is not necessarily always
effective and helpful.
9
Doctors, Administration, Pharmaceutical companies, Nursing
staff, Political parties and Government, Patients, Administrative
support. 1. Doctors, 2. Government, 3. Administration
Inside information have the doctors, pharmaceutical companies,
patients and the administration. The use of technology can change and
improve the administration of information.
10
Doctors, nursing staff, paramedical staff, technical staff,
administrative staff. 1. Doctors
Inside information is controlled by doctors and technical staff who have
access in information.
11
Doctors, nursing staff, technical staff of labs, social workers,
administrative staff, cleaning and other suportive staff (drivers,
workers etc), employees in information management office. 1. Doctors, 2. Nursing staff
There were some monopolistic phenomena of inside information but
now this has changed due to increasing use of technology. Now,
anyone who interest can find the information.
12
Doctors, nursing staff, pharmacists, administrative staff,
supportive staff in hospitals, paramedical staff, technical
services and technicians.
1. Doctors, 2. Paramedical staff, 3. Nursing staff, 4.
Administrative staff.
Doctors and pharmaceutical companies have inside information and
they form the information for the others. There are still monopolistic
phenomena. Technology may help in improving the information
administration.
13 Pharmacists, therapists, doctors, administrative staf, nursing
staff, paramedicals, technical staff.
1. Doctors, 2. Nursing staff, 3. Paramedicals, 4. Administratives,
5. Technical assistants.
All involved groups have some kind of inside information. Technology
can definitely improve the information administration.
14
Doctors, nursing staff, paramedical staff, administrative staff,
Ministry of Health.
1. Doctors / this is the most important group which plays crucial
role in current changes of the system as well.
Doctors has inside information and they are responsible for the
formation and administration of information. They are responsible for
the monopolistic phenomena which could be eliminated if technology
penetrates.
15
16 Hospitals Administration, Doctors, Nursing staff, Paramedical
staff, Administrative staff, Pharmaceuticals staff.
1. Hospitals Administration, 2. Doctors, 3. Pharmaceutical
companies Information is formed by outside centers such as Mass Media.
17
Doctors, nursing staff, technical staff, administration. 1. Doctors, 2. Nursing staff
Doctors have inside information and they are responsible for forming
the information as well. There are no monopolistic situations in terms
of information administration, and technology can help in the
development and restrain information asymmetry.
79

18
Doctors, nursing staff, pharmacists 1. Doctors, 2. Pharmacists, 3. Nursing staff
Information is administered outside the sector. Journalists and centers
of press are responsible for the infusion of relevant information. Use of
technology can help theoretically but not in practice.
19
Doctors, nursing staff, physiotherapists, pharmaceutical
companies, pharmaceutical central warehouses, pharmacists.
There are two strong groups which demonstrate their own
hierarchy; 1st group: (a) Doctors, (b) Nursing staff, ©
Physiotherapists; 2nd group: (a) Pharmaceutical companies, (b)
Pharmaceutical central warehouses, © Pharmacists.
Information is actually administered from pharmaceutical companies;
Monopolistic phenomena are referred to medicines and their markets.
These contribute in the rolling of information in the system. Use of
technology can definitely help in restraining information asymmetry.
20 Doctors, nursing staff, pharmaceutical companies,
administrative staff, other supportive staff (cleaning, cooking,
security etc), social services that participate in the system.
1. Pharmaceutical companies, 2. Doctors, 3. Nursing staff that
belong to unions.
Inside information exists among pharmaceutical companies, doctors
and University medical staff. Use of technology could help in terms of
clarity in the system and the relations among groups.
21
Doctors, nursing staff, administrative staff, supportive staff
(technicians, cleaning etc).
The most powerful group is the one that has the capitalised
strength to impose changes in the system. This is troika. The
privatisation of healthcare in the country is supported towards
specific interests. Therefore outside interferes due to political
decisions.
Actually none has full access to information. For example doctors have
restrained access. Nevertheless, it is absolutely necessary to ensure
accessibility to information, especially for the modern doctors.
22
Doctors, nursing staff, paramedical staff.
In a healthcare system which is doctor‐centered, naturally the
main role is played by doctors. Second, the nursing staff is
significant, since this is a new dynamic group which plays a
significant role as well and tries for advancement.
Pharmaceutical companies play the significant role in information
administration in the system. These companies decide who will have
access in information and the range of this access as well. Use of
technology is theo door for the modernisation and democratisation of
information for all.
23
Doctors, nursing staff, pharmacists, pharmaceutical companies,
supportive staff, physiotherapists, other technical staff.
1. Doctors, 2. Pharmaceutical companies. These two powers play
the major role in the sector.
Priviledged accesibility in information is focused on doctors who are
the main receivers of various information mostly from pharmaceutical
companies through pharmaceutical representatives. Free access in
technology and information will help the administration information.
24
Doctors, nursing staff, pharmacists, pharmaceutical distributors,
hospitals, ministry of health, pharmaceutical companies,
associations, unions, government, legislators.
1. Government, 2. Legislators, 3. Ministry of Health, 4. Unions, 5.
Doctors‐Pharmacists‐Pharmaceutical distributors‐Hospitals, 6.
Pharmaceutical companies.
Inside information has every group in terms of its own priorities.
Technology can improve information administration as well as the
control over information. It is true that during last years many groups
have access in information. Steps taken so far are small though but to
the right direction.
25
Doctors (private/hospital/clinical/insurance/University), Nursing
staff, Paramedical staff, Pharmacists, Pharmaceutical
companies, Pharmaceutical and Medical distributors and
wholesalers.
1. Pharmacists (due to their strong union), 2. Doctors, 3. Nursing
staff, 4. Paramedical staff.
Information asymmetry exists everywhere, since any group can gain
access depending on the resources it acquires. Information
administration is a broader issue of fair treatment and credibility.
80

26 Doctors, nursing staff, pharmacists, physiotherapists,
speechtherapists, ergotherapists, biologists, biochemists,
technology labs professionals, chemists, pharmaceutical
companies, pharmaceutical warehouses, technical assistants,
government, administrative staff of hospitals, insurance
organisations, insurance companies, state public services, the
national organisation of medicines.
Group A: Doctors, State, Pharmaceutical companies and
warehouses, Group B: Patients, Group C: Public Insurance
Organisations, Group D: Supply companies, Group E:
Administration, Group F: Lab professionals, Group G: Nursing and
paramedical staff.
There is information asymmetry since some groups form and
administer the information and these are groups A, D and F because
they have the ability to cooperate with external scientific communities
and have the knowledge. Nevertheless, the adoption of technology
gradually helps also patients and others. Monopolistic phenomena in
regards to information exist mostly from pharmaceutical companies.
Regarding the supply of goods, the monopolistic situation is less.
Regarding the information created by the government still the access is
restricted especially in terms of any changes in healthcare system.
27
Healthcare system is divided into public and private sectors in
the country. Players are: doctors, nursing staff, pharmacists,
dentists, paramedical staff, other supportive professions such as
drivers of ambulances, assistants etc.
All groups have power and play significant role but if we would
like to prioritise them we have to consider the level of healthcare
provision (First‐Second‐Third). In first healthcare level, doctors,
nursing staff and paramedical staff are important. In the other
two levels of provision, doctors, nursing staff, dentists,
paramedicals, assistants. In all these provisions, it is necessary
the existence of pharmaceutical companies. Most powerful
groups are doctors and nursing staff. These two groups with the
cooperation of pharmaceutical companies play significant role in
the system.
Inside information has to do with two issues. First with the information
that is produced by private companies and non‐governmental
organisation which create information and promote it for various
reasons, e.g. advertisments, mostly for their personal interests. Such
groups have direct access to the society. Regarding medical issues,
pharmaceutical companies still have the power to form information.
They create monopolistic situations and this affects the economy of the
country. Pharmacists used to be a powerful monopolistic group as well,
at least until some time ago. Regarding doctors, any inside information
has to do mostly with their scientific tasks, since their job is too
specialised. Any monopolistic behaviour is related to the nature of their
job and expertise which among others, is very significant for the
society.
28
Doctors, nursing staff, administrative staff, paramedical staff,
psychologists, economists, lawyers, politicians. 1. Politicians, 2. Doctors, 3. Lawyers, 4. Economists, 5. others.
All groups have access and form information. Possibly doctors might
have some privileged access. There are no monopolistic phenomena in
the sector. Technology can help in the administration of information.
29
Doctors, nursing staff, politicians, technical staff, supporting
staff. 1. Politicians
Politicians have more accessibility to information. Technology could
improve information administration.
30
Doctors, nursing staff, pharmaceutical companies,
administrative staff, pharmacists.
Most powerful groups are: 1. Doctors, 2. Nursing staff (Heads). In
current situation, primary role are playing pharmacists.
Information is administered by nursing staff and the pharmacists.
Pharmacists have priviledged access to technology. Technology, as a
mean could help in better information administration.
81

31
Doctors, paramedical staff, pharmaceutical companies,
administrative staff. All categories have power in the sector.
There are monopolistic phenomena in the sector, in regards to
information administration, but technology will help and it is
necessary.
32
Doctors, nursing staff, paramedical staff, pharmacists,
pharmaceutical companies, administrative staff, political staff. 1. Administrative staff
Doctors have better access to information since they form it as well.
Pharmaceutical companies on the other side create monopolistic
phenomena in terms of information administration. More use of
technology will help definitely the sector.
33
Doctors, nursing staff, pharmaceutical companies,
administrative staff. 1. Doctors, 2. Nursing staff.
Doctors and administrative staff are responsible for the information
generation. Use of technology may improve information
administration.
34
Nursing staff, Doctors, Technical medical lab assistants,
pharmacists, administrative staff, technicians, biomedical staff,
physiotherapists, ergotherapists, psychologists, social workers.
1. Doctors, 2. Administrative staff, 3. Nursing staff, 4. Technical
staff, 5. Paramedical staff.
Doctors and nursing staff are the groups that create information. There
is no privileged access for any group. Use of technology could help in
the improvement of information administration.
35
Doctors, nursing staff, paramedical staff. The one group supports the other.
There is no actually a unique group that has more access in
information. Information administration is a matter of personal
initiative. As a result groups have restrained access. The use of
technology will definitely help.
36
Government and Ministry of Health, Administration of
Hospitals, Unions, professional associations, pharmaceutical
companies, doctors, companies that are involved in the sector.
The most powerful group is Government. Government does not
want any changes.
Government continues to administer information which still creates
problems although we live in the era of free information. Issues that
should have been solved remain unsolved.
37
Ministry of Health (central government), pharmaceutical
companies, doctors and nursing staff.
The most powerful group is Government. All other groups have
been eliminated.
Information administration is done by mass communication media. It is
not clear whether there are monopolistic phenomena.
82

(Englishversion)
How important are the relations among
agents in healthcare? Do relations play a
decisive role for the system? Is this
positive, negative, neutral?
Who defines the relations patterns in the
system? Who is responsible for the
relations; the system, the building blocks
of agents?
Do relations create interdependencies? Does
this create paradoxes in the system? Does
this reveal weaknesses?
What is the real nature of interdependencies?
Do they enable or block emergence and self‐
organisation?
(Greekversion)
Υπάρχουν σχέσεις αλληλεξάρτησης μεταξύ
ομάδων στον τομέα της υγείας στην χώρα μας?
Πόσο σημαντικές είναι αυτές και πόσο
επηρεάζουν την λειτουργία της υγείας?
Ανάλογες σχέσεις μπορεί να συμβάλλουν
θετικά ή αρνητικά σε οποιεσδήποτε εξελίξεις?
Ποιός καθορίζει τις σχέσεις αλληλεξάρτησης?
Κάποια ομάδα, συνδυασμός ομάδων, μήπως
το σύστημα το ίδιο λόγω της οργάνωσης του?
Μπορεί μια σχέση αλληλεξάρτησης να
δημιουργήσει παραδοξότητες ή να επιφέρει
στρεβλώσεις?
Μπορούν αυτές οι σχέσεις να προκαλέσουν
αλλαγές στο σύστημα? Μπορούν να βοηθήσουν
στην απελευθέρωση νέων υγιών δυνάμεων?
Μπορούν να οδηγήσουν σε μια νέα αυτο‐
οργάνωση?
1
There are strong relationships among agents in
healthcare, such as: (doctors‐nursing staff,
doctors‐pharmacists, doctors‐pharmaceutical
companies). These relations are significant for
the healtcare operation. They might have either
positive or negative effect.
Responsible for the definition of relations
patterns is the system. The way that this is
organised creates such distortions.
Since the system is organised in a rather
paradoxical way it is inevitable to avoid distrortions
and unbalanced relations.
Only changes in relations patterns could enable
changes in the system.
2 Yes, there are relations among agents which
affect healthcare operations. Might be positive
and negative at the same time.
Relations patterns are defined by the Law and
Institutional framework in general. In
continuous, agents‐groups and the system are
responsible for the application. Yes, relations may create interdpendencies.
Relations cannot create changes in the system.
They can help though the release of new powers
and they can help in a new self‐organisation.
Interviews' results on INTERDEPENDENCIES
83

3 It is true that there are relations among groups.
It is imperative for all services to operate in a
correct manner to gain results. Otherwise this
cannot be achieved.
Relations patterns are defined by the system
itself and they way this is organised.
Interdependencies are not necessarily negative. If
they do not operate in a correct manner this of
course may raise paradoxes and create
weaknesses.
There happen new attempts for the improvement
of relations and the interdependencies existed. The
introduction of new technologies is expected to
alter and help current situation towards emergence
and self‐organisation.
4
There are relations among agents which can
affect healthcare either positive or negative. Relations patterns are defined by the system.
Relations do create interdependencies which in
continuous create paradoxes and distortions.
Interdependencies could be positive and could help
in unleash of new powers towards self‐
organisation.
5 There are relations among agents which are
considered very important. These do play a
significant role in the system.
Relations patterns are defined by everyone,
every group and the system itself.
Interdependencies create paradoxes and generate
different perceptions about information and other
characteristics in the sector.
Such relations can direct to unleash of new powers
and self‐organisation.
6
There are interelations among agents. These
days that the system is in transition, still
doctors have the full power since they decide
which drug to give in the patient. Although the
system is on‐line, doctors define which
medicines will be given and patients do not
have the option to buy substance instead of a
given brand.
which is badly organised.
Relations create interdependencies as a natural
outcome of the system's setup. Nevertheless, such
closed relations could be avoided by placing
boundaries.
Interdependencies could be proved beneficial for
the system. For example these could be direct to
the decrease of pharmaceutical spending and
improvement of relations among doctors‐patients.
7
Relations among agents are very important.
These must exist since they help in the
advancement of healthcare as service and
science.
The system is responsible for the patterns of
relations.
Relations create interdependencies and such a
characteristic creates paradoxes in the system. It
may create distortions and reveal weaknesses.
Real interdependencies could direct in new
organisation, through generation of new powers.
8
There are relations among agents. Such
relations are obvious on daily practice, but
when there are problems in collective level,
these does not necessarily work. Cooperation
among agent is too difficult and this does not
help the sector.
The system imposes the relations patterns.
Sometimes responsible for the relations are the
leaders of the groups who act on behalf of
other motives. The system demands the groups
to work independently in order to avoid further
correlations, but this is not feasible in the end.
Relations create interedependencies and may
direct even in the change of management and
people in charge.
Interdependencies serve internal purposes for the
system. They could enable emergence but this
requires change of mentality as well.
Interdependencies cannot help positively unless
there is cooperation among agents, exchange of
ideas, common perspectives and willingness to
succeed. All these are too difficult to take place in
the sector.
9
There are relations among agents, which are
considered very significant. Such relations can
affect either positive or negative.
itself. The interdependencies developed are
mutual for all groups in the system.
Interdependencies create distortions and
paradoxes.
Interdependencies enable emergence and self‐
organisation especially in the case of a clear,
balanced and mutual benefit cooperation among
groups in the sector.
10 There clear relations among agents and these
raise positive contribution to the system.
The relations patters are defined by the
healthcare system. Relations create interdependencies.
Interdependencies help in revealing new powers
and may direct to self‐organisation.
84

11
The relations among agents are very important
as long as these are acting as groups and not as
leaders who would like to stratify people into
leaders and followers. Healthcare is affected
negative whenever groups are not acting as real
groups. Therefore, there is a need for
consensus and link which will act positively.
The relations patterns are defined both by the
groups and the system in combination with
knowledge and common interest towards
better services to patients. The system due to
inadequacies is an obstacle in any
development.
Interdepedencies are not negative as long as there
exists the common knowledge of intersupport and
mutual respect among members. The good
organising, programming and consensus does not
bring paradoxes in the system.
Real interdpendencies bring new powers and
changes in the system, along with better results.
Self‐organisation requires better schooling to be
effective.
12
There are relations among agents, which are
very decisive in affecting healthcare services.
Such relations may raise positive or negative
effects.
itself.
Interdependencies as a result of relations patterns
followed, create paradoxes and distortions. Interdependencies can reveal new powers.
13 Relations exist among agents and these are
very important.
Relations patterns are defined by a group of
groups. Relations do create interdependencies.
Interdependencies can direct to new structures and
self‐organisation.
14
There are relations among groups for example
doctors with nursing staff, these are very
significant and play crucial role in the sector. Relations patterns are defined by the system. Relations create interdependencies.
Such relations and interdependencies could cause
changes in the system. They could lead to a new
self‐organisation as well.
15
16
Relations among groups exist and are very
significant.
Relations patterns are defined both by the
system and some groups. Actually the structure
of the system helps preservation of current
patterns.
Relations create interdependencies and this
creates paradoxes and distortions.
Current powers cannot help in self‐organisation and
cannot contribute in revealing new powers.
17 The relations among agents are very important
and there are strong interdependencies which
affect the progress of the system as a whole. Relations patterns are defined by the system.
Interdependencies may raise paradoxes but from
time to time, not always.
Interdependencies may help in unleashing new
powers towards a new self‐organisation of the
system, but I do not know if they can direct to
changes.
18
Of course there are relations among agents in
the sector. Although these are not considered
important, there exist and unfortunately affect
the sector. As a result such relations might play
either a positive or negative role.
Relations patterns are defined by a
combination of groups and the competition.
Yes, relations create paradoxes and distortions and
actually this happens very often.
Such relations might enable changes but in a small
range. Regarding emergence and self organisation
this necessitates the cooperation of various factors
and powers.
19
There are strong pairs of relations among
agents such as: doctors‐pharmaceutical
companies, pharmacists‐pharmaceutical
warehouses and distributors, pharmaceutical
companies‐pharmaceutical distributors. Such
relations play significant role in the sector since
these define the framework upon the system
works on. These contribute both negatively and
positively since these define any developments.
The answer is the system. The system has been
structured in such a way that nobody can
proceed alone. Everybody needs everybody.
There is equivalence among groups and
interdependencies demonstrate a kind of
equivalence among the groups as well. Such
organisation of powers could create paradoxes.
Groups and their interdependencies have the
power either to block or boost emergence and self
organisation.
85

20
Relations among agents exist and are very
important.
Relations patterns are defined by the
government and its agencies which create the
framework.
Interdependencies are result of relations which
exist, such as between doctors‐pharmaceutical
companies. A paradox stemmed from
interdependencies is that many valuable staff
decide to leave healthsector and go abroad.
Such relations may destroy the whole system.
Healthy powers cannot succeed if current system
remains.
21
The whole system is built on relations and
interdependencies. This is how it is structured.
In any case, this implies the definition of a
system. Any progress is result of how such
relations operate and affect participants and
groups.
The system defines relations patterns in
general terms. Of course this, from time to
time, is affected by personal interests of
groups. Certainly such relations create paradoxes.
The system is strongly structured and with strong
interdependencies and relations. As a result, given
the current situation, it is difficult for the system to
reach a new self‐organisation and new powers to
be revealed.
22
Doctors have direct relationship with
pharmaceutical companies, something that is
acceptable to an extent, but beyond this, in
general, it is dangerous for the fair treatment of
patients.
There are strong castes within medical group
which affect the system and reproduce current
mentality for the benefit of these groups.
Certainly relations create interdependencies which
generate paradoxes. Such relations affect patients
negatively.
Personal and independent reaction is much more
important than interdependencies. Every
participant in the system should consider carefully
his/her participation and action and should fight for
the best.
23
The relations among agents in healthcare, are
relations of interdependence and interaction.
Such relationships could boost knowledge on
the one side, while on the other side could
affect negatively.
The healthcare system itself, and the way this is
structured defines the internal relationships.
There are specific relations that create
interdependencies in the system. Such relationship
is between doctors and pharmaceutical
representatives which damage the sector and bring
paradoxes. No comment
24
The relations among agents are very important
and to an extent that affects the supply chain of
the system.
The governments so far and their mechanisms
are responsible for the relations patterns.
These relations exist and have definitive stress
regarding any evolvements in the sector. They do
create paradoxes and problems in healthcare.
State and government are the entities who usually
block any progress due to their low level of
intelligence, information and knowledge they have.
25
Certainly there are relations among agents
especially between doctors and pharmaceutical
companies. This relationship has both negative
(over‐prescriptions of medicines) and possitive
(pharmaceutical companies fund research and
organise congresses) effects. The wrong
manipulation of such relationship may direct to
commercialisation of healthcare.
Mainly the system defines relations patterns
and this is due to the existed ankylosis.
Relations create interdependencies since the
human factor demonstrates emotional
vulnerabilities or even money dependencies.
It would be wrong to allow the sector to a new self‐
organisation at least without control, unrestrained.
86

26
Of course, there are relation and
interedependencies among groups in the
sector. Actually there is a chain of relations
among groups which is very significant for the
survival of the sector. Such interelations define
policies and how these are applied. On the
other side, these different relations are
responsible for the different implementations
of the same policies in the same sector.
The system defines the interelations. The
system and its organisation, enables groups
and allows such relations.
Relations do create interdependencies and these
raise paradoxes mostly stem from the groups that
are in the beginning of the chain of relations. These
are: administration‐government, administration‐
doctors, doctors‐pharmaceutical companies.
Interdependencies create obstacles and block any
new powers. Current system does not have a fair
system of evaluation and control. For example,
doctors choose specific medicines and promote
specific health tests. Under these circumstances,
any progress is difficult. In addition, the sector has
many groups which have many interelations,
therefore it is difficult to find its self‐organisation.
27
Of course there are interelations among
groups. A classic relation is among doctor‐nurse
in the level of daily practice within the clinic.
Interelations are also among other groups in
terms of cooperation for the benefit of the
sector, in areas that is not so obvious. There are
though some interelations that should be
stopped such as between health professionals
and pharmaceutical companies for personal
benefits.
The system defines the relations patterns in a
certain extent. Since the staff is obliged to
cooperate and interact, it is inevitable not to
exist relationships. The nature of such
relationships and whether these are positive or
harm the system depend on the personalities
of the participants.
Paradoxes and distortions do exist only in the
occasion of misusing these relations for personal
benefits.
It is possible for the interdependencies to enable
new structures and organisations without creating
problems in a hospital for example. Good relations
and interdependencies could create new units,
clinics and develop the environment for new
cooperations. Such services though should always
be available to all patients and not only to the rich
ones.
28
There are relations among groups which are
important because they affect the operation of
healthcare provision. In addition they affect
both positively and negatively the progress in
the sector.
The system defines the relations patterns. This
is due to how this is organised and the existed
structures. Current system is doctor‐centered
focusing in classical ways of managing and
hierarchy.
Interdependencies could create paradoxes only in
the cases of individuality, competition,
introversion, intolerance and autarchy.
Interdependencies may cause changes but this
prerequisites a good administration of change,
knowledge, persistence and cooperation.
29
There are relations among agents which are
important and may contribute in any
evolvements in the sector both positively and
negatively.
Relations patterns are defined by personal
initiatives. Relations do create interdependencies.
Such interdependencies can cause changes in the
system.
30
There are strong relations among groups.
However, now that prices are controlled,
relations change especially between doctors
and pharmaceutical companies.
All the above, are responsible for defining
relations patterns.
An interdependence might create paradoxes in the
system.
It is difficult for interdependencies to enable new
powers and a new self‐organisation in the system. I
see this accomplishment as very difficult.
31
There are relations among agents which are
very important and contribute positively in the
progress of the sector.
Both the system and the building blocks of
groups are responsible for defining relations
patterns.
Relations create interdependencies and this
enables paradoxes and distortions.
Interdependencies could enable changes, as long
as, there will take place some radical changes in the
structures of the system.
32
There relations among agents which are
important. The system defines relations patterns.
Relations create interdependencies and these
create distortions.
Such interdependencies could enable emergence of
new powers in the system.
33
Relations among agents are important and
contribute positively in the progress of the
sector.
The system defines relations patterns. The
Directors of Clinics are responsible for the
relations.
Relations and interdependencies create paradoxes
in the system.
Such relations could help the system. They could
help in unleashing new powers subject to successful
selection of new staff. This needs patience and
persistence.
34
There are relations which are important and
could be used for the benefit of the healthcare
sector. Especially for the benefit of patients.
The interelations and relations patterns are
defined by the system and the groups.
When relations are not equivalent then there are
distortions.
Relations could enable changes in the system and if
these relations are healthy could change the whole
system.
87

35
Interelations are inevitable in an environment
where strong relations exist. These are positive
and necessary for the system. The groups define relations patterns.
Distortions are the result of personal actions and
not the result of interdependencies.
Interdependencies can cause changes through a
series of interactions among groups.
36 There are relations among groups that create
dependencies in a degree of high protection.
The system defines relations patterns and
founds itself at the beginning of chain.
There are no paradoxes in the system since each
group knows that depends on the others. Such relations could enable changes.
37
Healthcare is affected by all its members.
Relations are very important. When a sector
malfunctions affects others as well and
decrease the level of healthcare provision. The system defines relations patterns.
There are paradoxes and distortions for which the
system has therapies.
New healthy powers will direct to new self‐
organisation.
88

(Englishversion)
What is heterogeneity in healthcare?
Where and how this is identified? What kind of problems
does this create? Can heterogeneity be a source for development?
(Greekversion)
Στο σύστημα υγείας συμμετέχουν διάφορες ομάδες? Υπάρχει
διαφορετικότητα μεταξύ των ομάδων, παρόλο τους κοινούς
στόχους που ενδεχομένως έχουν? Εάν υπάρχει
διαφορετικότητα, πόσο ευρεία είναι αυτή?
Σε ποιούς χώρους του τομέα, μπορούμε να διαπιστώσουμε εάν
υπάρχει διαφορετικότητα? Εάν τελικά υπάρχει διαφορετικότητα,
αποτελεί αυτό πρόβλημα για την χώρα? Πιστεύετε ότι η διαφορετικότητα μπορεί να είναι πηγή εξέλιξης?
1
There is heterogeneity in the participative agents and this is
the main cause for the deviation from the common target
which is providing good healthcare services.
This could be observed mostly in nursing area and the
pharmaceutical care provision. Especially in these two areas
heterogeneity is a problem for healthcare.
Heterogeneity could be, in general, a source of development for
the sector.
2
There are differentated groups in healthcare and there is
heterogeneity among them. This differentiation is rather wide
in terms of different approaches in the sector.
The areas of medical doctors is a suitable area to identify this
diversity. This is more obvious in hospitals and within administrative
services. Referring to hospitals we may include Health Centers of the
country (Kentra Ygeias), Peripheral Medical Units and Hospital
across country. This diversity becomes a problem for the sector.
Heterogeneity and diversity could be a source of development but
could become also a brake in any kind of evolution for the sector.
3
There is diversity and in extent heterogeneity in healthcare.
Different groups are participating.
4
There is heterogeneity in Greek healthcare sector which
demonstrates rather a wide range.
Heterogeneity and diversity could be observed mostly in medical
and administrative staff as well as in nursing staff. The differences
among these groups creates problems in healthcare and especially in
the operation of hospitals. Diversity and heterogeneity could not be a source of development.
Interviews' results on HETEROGENEITY (DIVERSITY)
89

5
Heterogeneity is the normal result of the different targets that
each group has in the sector. For example: Doctors and nursing
staff have same targets which in the same time are different
from administrative and technical staff. Different groups,
different targets.
Heterogeneity is not a problem, since different groups have different
actions because off the different objectives. Heterogeneity and diversity can be a source of development.
6
There exists heterogeneity in the Greek system, but most of
the times this is not accepted. As a result diversity means
minority.
7
There is diversity in the sector and it is wide.
Diversity and heterogeneity could be observed in many places and is
rather a problem, not only for the sector but for the country as well. Heterogeneity could be a source of development.
8
Heterogeneity in healthcare is the difference among agents in
various areas such as knowledge, expertise, tasks, nature of
job itself. There is much difference but common elements are
many and all groups in healthcare have things that unite them.
Diversity and difference usually create problems in communication
and understanding between people. This is more obvious when one
group cannot understand the problems of the other group. In a
complex system this weakness, isolates the groups and they cannot
see the benefit for the whole system.
Heterogeneity can only be a source of development if groups can
find common ground to meet and discuss. Only in this situation
pluralistic approaches could be beneficial for all and each group
will realise that emphasis should be given in strong points rather
than weaknesses.
9
Heterogeneity exists in terms of rewarding, personal interest,
specialised duties. Such characteristics create contradicted
relations.
Heterogeneity exists in all areas of the sector. This can be a problem
for the country unless there exists a framework of common
principles accepted and applied from everyone. Diversity could be a source of development.
10
There is no real heterogeneity among groups in healthcare
sector.
Heterogeneity does not exist and does not create any problems in
the healthcare system of the country.
Real heterogeneity and diversity, if exist, can be source of
evolvement.
11
Heterogeneity in healthcare stems from the different
professions that exist in healthcare. Heterogeneity is cultivated
through education most of the times but through years is
eliminated through experience. Hererogeneity is everywhere and usually does create problems.
By itself cannot be a source of development, but it can be in
combination with other factors.
12 Heterogeneity is the phenomenon of the existence of different
groups in the system. This heterogeneity is wide in healthcare.
Heterogeneity exist mainly in medical and paramedical areas, but it
does not consist a problem for the country unless it affects the
cooperation of groups. Heterogeneity may be a source of development.
13
There is heterogeneity in healthcare, and this is due to the
different objectives of the groups. Nevertheless, they have
common targets in the frame of healthcare. Heterogeneity is mostly identified in administrative sector. It can be source of development.
14
Heterogeneity exists and mostly refers to development and
financial decisions. Hererogeneity could be better identified in hospitals. Yes, heterogeneity can be a source of development.
15
16
There is heterogeneity and this is rather wide in the sector.
Heterogeneity sometimes blocks cooperation and consensus,
therefore this is a problem for the sector. Heterogeneity may be a source for development.
17
In healthcare there are different groups which produce
heterogeneity. This difference among groups is huge.
Heterogeneity could be observed everywhere in the sector and this
does not create any problem for the country. Heterogeneity could be a source of development.
18
Heterogeneity stems from different initiatives and targets that
different groups have. This heterogeneity demonstrates a big
range.
Motives and results are the main attributes of diversity.
Heterogeneity creates problems for the country in general. The only
way to help positively is when this contributes in forming a clear
competitive environment.
Heterogeneity could be a source of development only when this
operates productively and correctly.
19
There is heterogeneity and its width is defined by the
initiatives and wills of each group seperately. Heterogeneity
demonstrates an additional grouping such as Pharmacists‐
pharmaceutical companies‐distributors.
Heterogeneity could be observed and found everywhere. If
heterogeneity is administered succesfully it will not create problems. Heterogeneity can be a source of development.
90

20
There is no heterogeneity in healthcare system. There is no heterogeneity in healthcare system. Heterogeneity and difference do not exist in terms of evolvement.
21
Definitely, heterogeneity exist in the sector. This stems from
the different aims, roles, motives and attitudes of the groups
that work in the sector. Responsibilites are different as well.
Some specific employees, especially doctors, have the primary
responsibilities in the system.
Heterogeneity could be observed in any place, espceially where the
clinical work takes place. In back up operations, such as lab
assistants, administration, heterogeneity is not so obvious.
Heterogeneity is more of a source of problems and tensions rather
than a source of development. Heterogeneity is something that I
do not recognise.
22
In the sector there are different groups which do not
necessarily have common ground for cooperation. There is
heterogeneity which is revealed through evolvement of things.
Every group is an equally active member and a possible
attractor for change, attracting the others to better prospects. Heterogeneity is sourced from people mostly and not groups. Heterogeneity should be a source for development.
23 No comment No comment No comment
24 No answer No answer No answer
25
Diversity‐heterogeneity is a general phenomenon in all labour
fields. Of course, each group has its own specific aspirations
and this by itself brings differences.
Heterogeneity could be observed mostly in hospitals and this is not
found only in Greece but in other countries as well. Heterogeneity could be a source of development.
26
Heterogeneity exists especially in terms of scientific
orientation and education, the level of knowledge and
abilities, the level of responsibilities. Also heterogeneity
includes any personal ambitions and individuality.
Heterogeneity could be seen in all sectors and this is not negative for
the country.
Heterogeneity can be a source of development if personal
differentiation could be homogenised for the common benefit
under an effective administration.
27
There are different groups in the sector but with common
targets and common vision. There is heterogeneity but this
does not make them different for the benefit of the services
provided.
Heterogeneity could be mostly seen in hospitals. Sometimes
heterogeneity is cultivated by the system and transforms internal
groups since they do not have the same treatment from the system.
For example, during crisis, there are hospitals that are obliged to
cope with much more patients although they do not have the
appropriate budgets. This is more intense in specific areas such as in
the hospitals of Epirus. Therefore, there are not only the given
heterogeneities but also the ones that are nurtured by the system
itself. If the situation was better heterogeneity and
interdependencies would be creative and finally would help much
more.
Probabably heterogeneity is the source of development but it
cannot progress alone without the help of society and vision from
the staff which abort any negative relationships.
28
There is heterogeneity but this is not wide. Since groups have
common targets they interelate and co‐exist in a common
route.
Heterogeneity exists and starts from the education of different
groups. This is not a problem though as long as there is consensus
and groupwork.
Yes, heterogeneity could be a source of development but with the
help of cultural changes and change in mentality.
29
Heterogeneity exists due to different obligations and different
targets of the groups that exist in the system.
Heterogeneity do not create problems as long as there is effective
cooperation among member groups. Heterogeneity could be a source of development.
30
There is heterogeneity among groups and this is based on the
difference in responsibilities and tasks. Doctors care for
patients, companies work for keeping doctors satisfied, nurses
are in the middle and administration might or might not
interfere in these relations.
Heterogeneity could be seen in hospitals. Sometimes it could be a
source of problem especially when there are no controls, e.g.
uknown medicines that are used in the sector. Heterogeneity could not be a source of development.
31 There exists heterogeneity but not in a wide sense. Heterogeneity is not a problem for the country. Heterogeneity could be a source of development.
32 Heterogeneity exists in the system. Heterogeneity could be seen in hospitals. Heterogeneity could be a source of development.
91

33 There is heterogeneity which stems from different purposes
and targets. These differences could break balances.
Heterogeneity is a problem, especially in the workplaces. This is
more emphatic when incapable people work in the sector affecting
badly the quality of employment. It is not necessary that heterogeneity is a source of development.
34 There is heterogeneity among groups in the sector and this is
due to the specialties of each profession.
Heterogeneity exists between two main groups. From the one side
doctors and nursing staffadn from the other side administrative,
paramedical and technical staff. If heterogeneity is creative then could be a source of development.
35
Heterogeneity exists due to different groups. This is wide and
necessary for the sector.
Heterogeneity stems from the multiple roles of structures in
healthcare. The bottom line is the effective therapy and treatment
of patients. As a result heterogeneity is not a problem since this
does not affect the quality of offered services.
Yes for sure, diversity is always a leverage for thinking and acting
towards results.
36
There is heterogeneity but the target is the same. More profit
from the sector.
The heterogeneity is not accepted in the sector because if this was
accepted we wouldn't enter in crisis. Heterogeneity creates progress and this is the solution.
37
Heterogeneity depends on different groups and these groups
converge. The more diversity exists among groups the more
diminishing services are offered.
Heterogeneity could be identified in central government,
universities and hospitals. Nevertheless this is not a problem for the
country.
Heterogeneity could be a source of development if all groups
decide to evolve.
92

(Englishversion)
What is an attractor pattern? Who is an attractor in the
current healthcare system in the country?
How these patterns work in the system? Do these impose
contexts? Is this possible for a new attractor to emerge
from changes in structures?
Can the system work without attractors? When/Under which
circumstances attractors take responsibility and protect the
system?
(Greekversion)
Ποιοί καθορίζανε και καθορίζουν τα πρότυπα συμπεριφοράς μέσα
στο σύστημα υγείας της χώρας μας?
Πως λειτούργησαν και λειτουργούν τα πρότυπα συμπεριφοράς
όσο αναφορά την εξέλιξη του συστήματος? Μπορούν τα
πρότυπα συμπεριφοράς να αλλάξουν σε ένα νέο σύστημα
οργάνωσης?
Θα μπορούσε ένα καινούριο σύστημα υγείας να προοδεύσει βασιζόμενο
στις υπάρχουσες και παλιές δυνάμεις του? Θα μπορούσε να αντέξει τις
έντονες μεταβάσεις στην νέα αυτο‐οργάνωση? Ή θα ήταν καλύτερο να
διαλυθεί και να ξαναχτιστεί σε νέα θεμέλια?
1
Firstly, the Law framework, but since there is absence of control,
reporting and evaluation, such patterns are defined by personal or
agents' interests.
Attractor patterns plays a crucial role in the system's evolution. I
consider that these patterns will not change easily in a possible
change of the system.
It is impossible to destroy and re‐build the healthcare system of the
country. There must take place radical changes based on existed and new
powers.
2
Attractor patterns are defined by the informal institution's
framework, the informal professional organisations, trade unions,
and social prejudices.
Existed attractor patterns have been negative for healthcare and
it is imposed to be changed. I consider that the system should be re‐established.
3 Attractor patterns are the Ministry of Health and the Law
framework. These groups direct patterns of behaviour.
In general terms these patterns of behaviour worked positively. If
the system changes the patterns of behaviour will change as well.
The new system should be based in current and older powers to rebuild
using attractors and trying to overpass previous distortions. We do not
need another catastrophy.
4
The main attractor in the healthcare system is the Public Code of
Professional Ethics for the employees in the sector.
Patterns of behaviour should be followed from everyone. They
could change in a new system.
The system cannot work without attractors. Healthcare should be re‐built
but with the exploitation of older powers. Nevertheless, the
characteristic that should be changed is mentality.
5
The attractors in the system are all agents themselves. The system
defines the Professional Codes of Ethics, but groups implement
them or not. Patterns of behaviour may change in a new system.
The rules have to change, the operational processes have to change, the
Management of hospitals need to change.
Interviews' results on ATTRACTOR PATTERNS
93

6
Attractor patterns are defined by the system and its organisation.
In continuous this is exploited by groups such as doctors,
pharmacists, companies etc. When there is no control and
measurement in a system then there is no punishment and decay. The old system should be kept and be re‐structured.
7 All agents that participate in the system are attractors and
contribute in the formation of attractor patterns.
Patterns of behaviour operate both negative and positive. They
can affect and change the system towards new structures.
The system should be destroyed and rebuilt from scratch based on new
axes.
8
Attractor patterns and patterns of behaviour are defined by the
educational system of the country. Especially University education
and the mentality of academic professors play a significant role in
the perception of healthcare system. For example, the traditional
view about the doctors' status in the system.
Attractor patterns does not help the evolvement of system, but
they maintain it in the same position. A new system demands new
patterns. The challenge is to create a new system based on
existed patterns but adapted to new needs and new targets. To
copy patterns from others is not useful.
The system cannot work without atractors. It would be ideal to destroy
the system and build it from the beginning but this is unrealistic.
Unavoidably we should follow a transition stage where older powers will
mix with newer and together will lead changes.
9
Attractor patterns are not specific groups or persons rather than
our mindset, cultural approaches, job environment and personal
interests.
Patterns of behaviour can change the system. But this demands
time since the prerequisite is to introduce and accept first new
prototypes.
The new system could be born from the old one, could be rebuilt, could
be regenerated, but not destroyed.
10 Pharmaceutical and medical companies are the attractor patterns
who additionally define the behavioural patterns in the system.
Behavioural patterns and attractor patterns operate in terms and
towards profit making. This target, defines behaviours and
development in the system. The system should be rebuilt from scratch.
11
Attractor patters are generated over the system's weaknesses.
Wherever there is a gap there is something new born. And this was
a mistake so far.
Current attractor patterns do create problems. But these can
contribute in changing structures.
The system should restructure itself using old and new powers as much
as possible.
12 Attractor patterns are affected by our education system and
administration which cultivates this system.
Behavioural patterns were affected by attractor patterns in a
monopolistic and backward way for the system.
The system should be destroyed first. Then we should built on new
foundations.
13
Attractor is the Ministry of Health for the system in Greece. Attractor patterns can enable changes and can impose contects. The system should be built on new foundations.
14
Doctors are attractors in the system.
Attractors form patterns for their own benefit. As a result they
may either block or help changes in structures.
The system cannot work without attractors and should be built on older
and new powers.
15
16
Attractors are the top management of hospitals and the doctors.
Behavioural patterns will not work unless managers and doctors
change their patterns.
Unfortunately the new system should be built from zero and the old one
should be destroyed.
17 Attractors are not persons or groups rather than the law, ethics
and the framework that exists and everybody follows. Behavioural patterns can certainly change A new system could be based both in old and new powers.
18
As attractors we can define doctors and pharmaceutical companies
and these groups form the relevant patterns as well. Mainly this
starts from pharmaceutical companies.
These patterns work both positively and negatively. Nevertheless,
these impose contexts and they additionally can help changing
the structures. The system should be destroyed and be rebuilt from the zero.
19
Attractor patterns are formed by attractors who are the leaders of
the groups that participate in the system. These leaders define the
behaviour of the members.
Patterns operate both negatively and positively and these may
change contexts or even create new contexts in the sector.
On the one side the system cannot work without attractors. A system
cannot be based in its old powers, if this wants to survive. There are
needed dramatic changes which mostly deal with the existing culture and
mindset. Such a system cannot withstand a transition in a new stage.
Therefore, i consider that the system should be destroyed, and be
created from the beginning.
94

20
Attractors in current system are trade unions and parties who
cultivate the relevant patterns. Rest of participants just follow and
do simply their jobs. Some of them could be really good examples
for the ones though who are ready to see the difference.
Current contexts and behavioural patterns are imposed by the
pair: government‐unions who have destroyed productivity.
The system needs new attractors, in order to gain a new perspective. The
new system cannot base itself in old powers and mostly based on existed
mentality and culture. As a result, the old system should be destroyed.
21
Current attractors are the political mouthpieces who operate
under their own interests, such as the Administration of Clinics in
Hospitals, Directors etc., who are motivated by personal,
economic, legal and job distribution motives.
Behavioural patterns are always expressed within the system's
limits. Systems do not self‐organised. Such an attempt is rather
failured. On the contrary all members should work towards the
structure of the system.
The destruction and building on new foundations is the only solution, as
it seems from rational explanations. Current system does not allow for
restructuring and repairings.
22
There are no attractors. There are no examples and prototypes to
follow. This is something that we have to dig and find.
Behavioural patterns and the system can accept many changes
and everyone is responsible.
Nothing is possible to be built from zero. Everything is a result of
progress. Under this case there must be a progressive power which will
undertake the responsibility to lead changes.
23
The Greek healthcare system is doctor‐centered. Doctors are
attractors. The Government is an attractor as well. These two
define the patterns. No comment
It would be better for the system to be structured from zero level
without the commitments and the past previous practices.
24
State defines patterns in the system, so the State is the main
attractor who using the legal framework places guidelines and
restrains.
Such patterns introduce contexts. The main issue though is who
controls these contexts and who is responsible for being applied. No answer
25
Regularly attractors should be the Ministry of Health and the Code
of Ethics of the sector. But nowadays patterns are affected and
followed differently from different groups and seperately.
Patterns affect the system and may change the structures as long
as these are working for the benefit of healthcare.
The system cannot work without attractors. It would be better to keep a
combination of old and new powers in an effort to make changes in the
system. We should keep good practices from past.
26
Patterns are defined by the groups. Individuality plays a significant
role. Nevertheless, since healthcare is a significant element for the
society, patterns are defined also under the requests of society in
extent.
Patterns of behaviour can change. Already current restructure
have helped in better administration. Of course this mostly
concerns public services and organisations. Groups that work on
private sector follow other patterns under different schemes.
A system could progress based on knowledge, abilities and money. The
better use of resources and a better administration are enough for the
changes to take place.
27
Attractors are mainly the health professionals of the system. Then,
the government.
History has proved that patterns of behaviour followed did not
help the system. The change of the system is expected to alter the
behaviours as well. The turn to privatisation will possibly help the
system by creating competition and healthy ground for new
patterns.
The system could progress keeping the good elements from the past.
However it is necessary to apply new competitive techniques and destroy
any monopolistic phenomena for the benefit of healthcare provision in
the country.
28
Behavioural patterns are defined by the educational institutes.
Behavioural patterns can change in a new system and this is
common expectation in healthcare sector. A new system with a
new management towards quality and progress.
To destroy and build again a system that incorporates the negative action
of catastrophe. Our system is not so decayed. It needs a change of
culture, renewal and stimulation.
29
Attractor patterns are defined by the dominant groups. Patterns do not change in a system. The system should be destroyed and rebuilt from the beginning.
30
Attractors define patterns and these usually are the unions of the
groups. These are the professional associations that represent
employees.
Behavioural patterns have affected either positively or negatively
the sector. These patterns cannot change since the country does
not have enough resources. The system should be destroyed and rebuilt on new foundations.
31
The system itself defines behavioural patterns and each agent
separately.
Behavioural patterns have operated negatively so far for the
system. They can change though.
It would be better for the system to be rebuilt from the beginning on new
foundations.
95

32 Human resource is responsible for the definition of the patterns in
the system.
Behavioural patterns are definitive for the progress of the system.
But it is very difficult to be changed, there are few possibilities. The system could be better to be built from the beginning.
33
The ones who participate in the system are responsible for
attractor patterns. Patterns work both negatively and positively. The system should be rebuilt in new foundations.
34
Patterns and behaviours are defined by the society and its citizens
in every different phase.
Patterns could impose contexts and have the power to change
systems and their organisation.
A new system needs also the old healthy parts of the previous system. It
can improve the old parts through time.
35
Attractor patterns is the result of evolution. There is no any specific
dominant power that defines patterns rather than interaction
among members. I have already replied based on the above.
Nothing can be rebuilt on totally new foundations. Everything is under a
developmental relation between yesterday and today. This is a detailed
relationship to the end.
36
The powers that define attractor patterns are the ones who are
responsible for the current situation in healthcare sector and in
Greece.
Yes, the attractor patterns can impose contexts but there were
not the corresponded evolution all these years. It would be better to build again the system on new foundations.
37 Attractor patterns are defined by the politicians, the educators and
the church.
Behavioural patterns are not independent from the healthcare
operators. Behavioural patterns follow the rules of new self‐
organisation.
The system should depend on both old and new powers. In this way the
system will handle the transition normally and not through catastrophy.
96

(Englishversion)
What are generative relationships and
what is the difference with relationships
as discussed earlier?
Do generative relationships create
contexts in the system? Who is the
main source of such relationships?
Do generative relationships have
responsibility for fighting or enabling
changes in structures towards self‐
organisation?
Which is the relation between generative
relationships and patterns of behaviour? Can this
relationship be the cause of emergence?
(Greekversion)
Εκτός από τις ευρύτερες σχέσεις
αλληλεξάρτησης, υπάρχουν και ειδικότερες
σχέσεις προστασίας και αλληλοβοήθειας
μεταξύ ομάδων μέσα στον τομέα υγείας. Αυτό
είναι ένα γενικευμένο φαινόμενο, ή αποτελεί
ιδιαιτερότητα του συγκεκριμένου κλάδου?
Μπορούν αυτές οι σχέσεις ιδιότυπης
αλληλεγγύης να επιβάλλουν κανόνες στο
σύστημα?
Μπορούν αυτές οι σχέσεις να καθορίσουν νέες
δομές και οργάνωση?
Προφανώς αναφερόμαστε στις κλειστές σχέσεις μεταξύ
ομάδων συνήθως του ίδιου επαγγέλματος ή ιδιότητας.
Τελικά αυτό μπορεί να δημιουργήσει εμπόδια, σε ένα
πολύπλοκο σύστημα, όπως είναι η υγεία μιας χώρας?
1
There are strong generative relationships in
the sector, but this does not mean that these
could not be found elsewhere, on other
sectors, as well. Perhaps in healthcare, this
phenomenon is more intense.
Yes, unfortunately this is possible to be
done in the sector.
Generative relationships define new structures
and organisation of the system. (people defines
systems and not vice versa).
Yes, this creates obstacles. Closed relationships direct to
narrow perspectives, ideas and in restrained changes and
additions, which in continuous complicate any reforms.
2
Generative relationships could be found in
other professional sectors as well. Probably in
the Greek healthcare sector this is more wide
and intense.
Generative relationships may impose
contexts but in circumstancial and not in
holistic approach. Yes, from time to time this is possible.
The relation among generative relationships and patterns
of behaviour is close, therefore this specialty may create
obstacles for any further developments, this is very
possible.
3
Closed relationships always create problems, on every
aspect and in every sector.
4
Generative relationships are the basis of
protection and solidarity among agents, but
this is a broader phenomenon. In healthcare
there are such specialised relationships.
Generative relationships could imply
informally new contexts in the system.
Generative relationships could enable changes in
structures and organisation.
Closed relations is the link between generative
relationships and patterns of behaviour. Such relations
create obstacles in healthcare and may be the cause of
emergence.
Interviews' results on GENERATIVE RELATIONSHIPS
97

5
There are generative relationships among
groups.
Generative relationships cannot create rules
or imply contexts. Contexts are defined by
the Administration of hospitals.
Nevertheless, groups can work for the
alteration of such contexts.
Generative relationships cannot create new
structures by themselves.
Closed relations operate negatively and create obstacles
in the system.
6
Wherever there is no control, there are more
closed relationships even if these are
generative due to common interests and
status.
Usually the system does not allow closed
and distorted relations among agents.
Such relations include people that stand outside
healthcare sector. Therefore, it is difficult
generative relationships to enable changes within
the sector.
Closed relations create obstacels and quarrels among
groups. This does not help neither the secto nor the
players themselves.
7
Generative relationships is a broader
phenomenon which could be found in other
sectors and not only on healthcare.
Generative relationships create contexts
and could impose rules in the system.
In addition, generative relationships can define
new structures, or even enable a series of
changes towards self‐organisation.
Closed relations and closed groups are obstacles in the
system's progress.
8
The phenomenon of generative relationships is
a general characteristic and refers to all
sectors.
In healthcare, generative relationships
create contexts. From time to time these
create new informal rules which in long
range harm the sector. For example the
reward and promotion of specific persons
do not always take place with wide accepted
criteria, rather than with personal.
Such relationships could enable changes which in
addition could direct to right direction. The new
organisation of the system should quarantee
daily evaluation, objectivity in criteria and agreed
framework from all.
Relationships are linked to behaviour. Closed relations
affect behaviour. Nevertheless, healthcare should be
placed above personal or professional relations. The
system must ensure that health is the ultimate service for
all with equal access and treatment. All agents should be
rewarded and be paid under a strict logical scheme.
9
There are relations among groups which are
special and this is due to the sector's
characteristics. In general there are
everywhere generative relationships but in
healthcare are more specialised.
Generative relationships can impose rules,
either with direct or indirect ways.
Generative relationships enable changes but
there must be also governmental willingness to
support this decision.
Relationships and patterns of behaviour may raise
obstacles but this again depends on mechanisms of
control. Rules and control are the opposite of closed
relations.
10
Generative relationships does exist in any
sector. This is rather a general attribute in
communities.
Such relationships, in extent, could define
prototypes and create contexts.
In addition, such relationships could define new
The closed relationship among generative relationships
and behavioural patterns may be an obstacle or a cause
for emergence.
11
Generative relationships is a general
characteristic but in healthcare this may be
more intense.
Generative relationships create contexts but
they lack of good organising and educated
members.
Such relationships play a significant role but they
are not the only one in enabling changes in
structures.
This relationship could raise obstacles. Every kind of
relationship needs strong base. This relationship is
responsbile for the local mentality that cultivated all
these years.
12
Generative relationships are a discrete
characteristic of healthcare sector.
Such relationships may impose contexts in
the system.
They may define new structures and enable
changes.
They cannot though raise obstacles, but be the cause of
emergence.
13
Generative relationships is a rather general
characteristic in various sectors but probably
demonstrates some extra specialties in
healthcare.
Such relationships are embedding new
contexts.
Such relationships possibly enabling and not
fighting changes in structures.
Nevertheless, the relation between generative
relationships and patterns of behaviour can create
obstacles instead of emergence.
14 Such generative relationships are specialty of
healthcare sector.
Generative relationships do create contexts
in the system. Such relationships may define new structures.
Closed relations such as the link between generative
relationships and patterns of behaviour raise obstacles.
15
16 Generative relationships is a general
phenomenon.
Generative relationships may impose new
contexts in the system, if the system wishes
to do that.
Generative relationships can define new
structures and new organisation, if the system
wishes to.
The relation between behavioural patterns and
generative relationships can and definitely create
obstacles.
98

17 Generative relationships exist in other sectors
as well but in healthcare this is more intense.
contexts in the system. This is possible.
Yes, such relationships can define new
structures.
Closed relations create obstacles and raise blocks in a
system.
18 I consider that there is no other relationships.
There are no generative relationships.
Since such relations do not exist they cannot
create contexts or affect the system.
There are some kind of relationships in the sector
which enable changes in structures and
organisation.
There are some kind of closed relations which may create
obstacles.
19 The existance of generative relationships is a
characteristic of all sectors and professions in
the country.
Generative relationships could be used as a
leverage for changing contexts but the issue
is for the benefit of whom, this usually
happens.
Generative relationships have the responsibility
for enabling or fighting changes. But this depends
on the groups that will try to exploit this
priviledge.
Relation between generative relationships and patterns
of behaviour exist. The manipulation of them can create
problems or the opposite, help progress of the sector.
20
Generative relationships is a social
phenomenon result from the instict of self‐
presevation of a group which lives in a broader
complex system.
Generative relationships cannot impose new
contexts especially when mentalities are
offended and personal belongings are
jeopardised.
Generative relationships are not responsible for
any changes. The system as a whole is much
stronger and administers information. Any special relations cannot affect or block any system.
21
Generative relationships is rather a general
phenomenon but each sector such as
healthcare demonstrates its own
characteristics during the adoption of this
phenomenon.
Such relationships could impose contexts
and they do it already.
Generative relationships include a set of informal
principles. These principles are rather responsible
for structures, behaviours and organisation in the
system. On the contrary, the formal hierarchy is
not so significant and decisive in future actions.
Closed relationships as a result of generative
relationships and behaviours is what is known as "status
quo" in the sector. These are responsible for the
malfunctioning of the system, but it seems that they have
wide acceptance.
22
It is impossible for a sector such as healthcare
not to have generative relationships and
solidarity.
Generative relationships should be more
active and support a humanistic
environment in the sector.
Certainly, generative relationships are carriers of
change in a fluid and redefined environment.
The relation between generative relationships and
patterns of behaviour can find obstacles but not create. It
is required though such relationships to be based on
equality and fairness.
23
There are special relationships of mutual help
and intercoverage among healthcare groups.
Generative relationships may create
contexts. For example they impose silence
and camouflage in problematic situations.
Such relationships should be changed first, and
then create new structures. No comment
24 No answer No answer No answer No answer
25
phenomenon.
Generative relationships create contexts in
the system which operate either positively
(cultivation of common interests) or
negatively (oppositions).
Nevertheless, generative relationships do not
have such power to define new structures and
new organisation of the system.
In a complex system, closed and special relations may
certainly raise problems in the system. Not to forget that
aspirations of participants are not always the same.
26
There are relationships of protection and help
among groups which enable mistakes and
restrain prosperity for the people. In the public
sector, generative relationships are stronger
and decisions are taken on group basis where
any mistakes are undertaken by the
responsibility of the whole group.
Such relationship may create contexts in the
system. It is good though to take into
consideration patients' status.
Not necessarily. The healthcare system
demonstrates weaknesses but this is not due to
weak relations of protection and help.
Generative relationships may direct to new
structures and organisation, but the issue is who
will make the decisions.
Generative relationships is possible to create problems in
the system of a country, especially when dominant
groups take decisions. Dominancy creates distortions,
since every part of the system is useful and not only
dominant groups.
99

27
Generative relationshps do exist, and this is a
general phenomenon which could be found in
many other sectors. These relationships are
closer and more protective and sometimes
they could not be identified directly.
Depending on their power, such
relationships can affect and introduce new
contexts in the system.
Usually, generative relationships do not affect
positively the sector. It for sure that such
relationships should be separated from the
sector and the general provisional scheme.
These close relations are not always bad or negative for
the system. Sometimes these are necessary. This does
not mean that they cannot create problems in patients.
However, such closed relations are not so important
because they represent a small percentage.
28
Solidarity and help among groups is a general
phenomenon while in healthcare this is more
intensive due to the nature of the sector.
the system and this does happen in daily
routine.
There have to be made new mixes and
interactions, in order the relations to change
Closed relations means cliques. Such relations are
obviously obstacles in any progress and improvement in
the sector.
29
Generative relationships are a general
phenomenon.
Such relationships could impose contexts in
the system.
Also, generative relationships could enable
changes in structures.
Closed relations create obstacles in the system and block
emergence.
30
Generative relationships are rather a general
phenomenon.
No, the specific relationships cannot impose
conrtexts.
It might be possible to enable changes in
structures though. No comment
31
Generative relationships exist elsewhere as
well, but in healthcare sector could be found
more often. These relationshps could impose contexts.
They could enable new structures and
organisation. Closed relations could not create obstacles in the system.
32
Generative relationships is a specialty of
healthcare sector.
This kind of relationships could impose
contexts.
Generative relationships enable new structures
and organisation. Such closed relations may be an obstacle for the sector.
33
phenomenon.
the system.
Generative relationships enable changes in
structures towards self‐organisation.
The relation between generative relationships and
patterns of behaviour creates problems in the sector and
in the country. It is questionable who finally manages the
system.
34 Generative relationships os rather an isolated
phenomenon and not a general one.
Generative relationships could impose rules
in the system.
But they cannot define new structures and
organisation. Yes this relation can cause problems.
35
Generative relationships are the basis for
interaction, solidarity, humanity and help
among members. We have to consider that the
final receiver in the system is the human being.
Generative relationships impose an informal
rule and a code of ethics among their
members. Since this is rather a flabby
approach we could talk also for formal rules.
structures but it takes time.
The problem is where the new system will be based on.
The emerging powers will be the result of the mix of
different powers.
36
Generative relationships harm the system
because these are maintained from the groups
that have damaged it. No they cannot. No they cannot. Closed relations are the problem. It is time for clarity.
37
Generative relationships are the characteristic
of healthcare sector. Yes they can. It should be. Closed relations remain a problem and an obstacle.
100

(Englishversion)
What is collective reflexivity? What is the relation with
complexity? Who is responsible for reflexivity? The system, the agents? How reflexivity works in healthcare sector?
(Greekversion)
Τι θα χαρακτηρίζατε ως συλλογική αντίδραση? Υπάρχει σύνδεση
μεταξύ αντίδρασης και πολυπλοκότητας?
Ποιοί μπορεί να καλλιεργούν την συλλογική αντίδραση? Μπορεί να
είναι ομάδες? Μπορεί να είναι το ίδιο το σύστημα? Μήπως συνδυασμός
ή κάτι άλλο?
Πως λειτούργησε και πως λειτουργεί η αντίδραση και τα
αντανακλαστικά των ομάδων στον τομέα υγείας όλα τα προηγούμενα
χρόνια, μέχρι και σήμερα?
1 Collective reflexivity is the practice of coordinated attempt for
changes Collective reflexivity can be cultivated by groups.
Unfortunately, there is inertness during last years in the sector, in terms
of reflexivity. Groups do not present alertness in the coming changes.
2
Collective reflexivity is anything that demonstrates a practice of
group reaction such as: protest, strike, absence, retention, mass
pension. There is collective reflexivity and is result of reaction.
Responsible for reflexivity are the politicians and political groups plus
trade unions of the sector.
Reflexivity did not operate in an effective way so far. It used to operate
with no organisation, no programming, and with no targets.
3 I do not know.
4
Reflexivity is synonymous to reaction (e.g. strike). Any reaction
has direct link with complexity in healthcare.
Political parties and trade unions are responsible for collective reflexivity
and reactions.
Reflexivity works negatively in the sector and harms the whole system.
In general terms the system does not help qualified and valuable
employees.
5
Collective reflexivity is collective movement as reaction.
Trade unions and professional unions are responsible for collective
reflexivity in the sector. No clear to me, if reflexivity works positively or negatively.
6
Collective reflexivity is a group reaction but this does not exist
anymore under the new system, since healthcare professionals
will be obliged sooner or later to work independently and sign
individual contracts.
After so many years the result is that there is no consensus among
groups in healthcare.
Interviews' results on COLLECTIVE REFLEXIVITY
101

7 Collective reflexivity is the unique reaction of a group for its
benefit. It is not clear if reaction is linked to complexity. Not only the agents but also the system is responsible for reflexivity.
There is no solidarity, or consensus among the agents during the years.
This, in consequence. stops healthcare system from progress and keeps
it stacked in the past.
8 There is connection among reflexivity and complexity.
Complexity actually suspends collective reflexivity. In a complex
system it is difficult for a group to react effectively.
Reflexivity is directed from political parties and unions. All of them are
part of the system in any case. So, the system has its own andidote which
is collective reflexivity.
Reflexivity did not work effectively so far. It worked though in
occassions when basic rights were considered to be broken. The main
reason was that there was no consensus and group mindset in the
sector. Each group had its own beliefs and the reaction was rather
periodic without strength and duration.
9
Collective reflexivity incorporates elements of self‐imposement
towards new rules of work and behaviour.
Both the system, the groups and the employees themselves are
responsible for reflexivity.
Ineffectively, without concrete and definite results but rather with
inertia.
10
Collective reflexivity is expressed through any practice of
opposition. This usually comes as a result of complexity that
implies reactions. Trade unions are responsible for reflexivity.
Reflexivity works under the supervision of political parties all these
years.
11
Collective reflexivity is the action of doing smth in changing,
canceling, rejecting tactics that are considered wrong. This is a
result of the relation between reaction and complexity. Both the system and the agents may be responsible for reflexivity.
So far there was no reflexivity in healthcare rather than predefined data
and rules which were imposed and were followed through time.
12
Collective reflexivity is the unique, homogenised reaction of a
group. The combination of agents and the system is responsible for reflexivity. There is no actual reflexivity in healthcare.
13
There is collective reflexivity. The system itself is responsible for reflexivity.
Reflexivity is based on interdependencies and the combination of
groups' powers.
14 No comment No comment No comment
15
16
Not understand the question.
The system does not create or support reflexivity. On the contrary the
system tries to divide collective reactions. Which reaction? Which reflections?
17 Collective reflexivity is like the action of strike. I consider that
there is link between reaction and complexity.
Trade unions and parties are mainly responsible for reflexivity.
Moreover, government, the system itself and groups are also responsible
for cultivating reflexivity. Reflexivity have operated negative for the system.
18
Collective reflexivity is a way of group reaction such as strikes,
protests and in general group reactions of any nature. There is
relation between reflexivity and complexity.
A combination of all is responsible for reflexivity (the system and the
agents). Reflexivity works in both ways. Positively and negatively.
19
Collective reflexivity are the mass movements. There is a link
between reaction and complexity.
Trade unions are responsible in the country for collective reflexivity.
Especially there are specific groups in the country that lead this
reflexivity. Finally reflexivity is a combination of the systems and
individual groups.
Collective reflexivity has operated successfully so far, but now, any
things that have been acquired by the groups is about to be lost.
20
Collective reflexivity does not actually exist, because it proved
difficult for people and groups to communicate and cooperate in
terms of challenging new things.
Reflexivity is something which is technically produced by the system in
order to be canceled by it in the end.
Reflexivity operates like having experienced a brain stroke and now
does not understand anything at all.
21
Collective reflexivity is the group reaction and the cooperation
towards common targets. Though, there are not common targets
and desires in the sector. Reaction has not to do with complexity
itself rather with current prototypes of self interests that are
cultivated by current system.
Reflexivity comes when groups realise that they have more commons
than differences. Poverty, undervalue and other difficulties probably will
direct groups in collective reflexivity. Such situations drive majority
towards the desire for reaction.
Reflexivity does not work. Every time that any group tries to react there
are always oppositions in the system, which try to terrify, and
blackmail. The only way for reflexivity to work effectively is when there
is a decision for final abruption.
22
Collective reflexivity is the collective attitude towards a
phenomenon. It is probable such attitude to forward progress.
This is a healthy behaviour for the system. The system and its groups are responsible for reflexivity,
Reflexivity was based in the strategy of splitting the powers in order to
weaken them. It is time for a different "modus vivendi".
102

23
Collective reflexivity is the group reaction against something
specific.
The system and the agents are responsible for the cultivation of
reflexivity. Reflections of groups are delayed in the sector.
24 No answer No answer No answer
25
Collective reflexivity is considered the reaction of a group of
individuals that oppose to a certain attack in their interests.
Usually this covers their common interests and not necessarily
their personal interests.
Usually, unions are responsible for collective reflexivity as well as any
other associations. Reflexivity works ineffectively and unevenly so far.
26
Collective reflexivity is the action of people towards common
goals. There is connection between reflexivity and complexity
since groups that participate in the common action do not
necessarily have the same motives. Therefore, it is not always
given that groups will reach their goals.
The system is responsible for reflexivity and the groups are responsible
for the cultivation of reactions.
Reflexivity works positively in terms of pushing for changes in the
system which finally accept to do. There were always reactions from
groups for various issues (economical, human resource issues etc),
especially nowadays where the system works with many difficulties.
Nevertheless, reactions have impacts to weaker groups, such as the
patients. In addition, reactions are taken into consideration with delays
which harms the system.
27
Collective reflexivity is the sum of the efforts of a group wih
common expectations, targets, desires. Complexity sometimes is
possible to fire reflexivity and the opposite. As a result
complexity and reflexivity have a bothway relationship.
Collective reflexivity is created by the system. Nevertheless it is possible
to be created by closed groups which create general problems and
operate against the system with war mentality.
Reflexivity works a‐posteriori in the sector, when problems have alread
cretated and impacts are diffused. On the other side we should not
forget that due to reflexivity both staff and patients acquired some
rights.
28 Collective means altogether. Reflexivity has a negative meaning
and complexity a positive one. Collective reflexivity in the
framework of complexity is still something we are looking for.
Everyone is responsible for reflexivity. The creation of an environment of
collectivity is necessary to create a dynamic healthcare system.
Unfortunately, the rule of "action‐reaction" works very negatively in
healhcare, just as in other sectors as well. This operates for the benefit
of personal motives and interests. Nevertheless, healthcare should be a
multi‐side place, an open place of communication and professionalism.
29 Collective reflexivity is the mass strikes. Responsible for reflexivity are the groups' representatives. Reflexivity worked unevenly so far in the sector.
30
Collective reflexivity means group reaction and cooperation
among groups. This is not possible though, since there is strong
diversity and each group has its own targets and motives. Both system and agents are responsible for reflexivity.
Reflexivity works both positively and negatively. The truth is that in this
period the sector is going to experience very bad situations due to
crisis.
31
There is connection between reflexivity and complexity. Both the system and agents are responsible for reflexivity.
Reflexivity did not work as expected, since the system was not
organised well.
32
Collective reflexivity is any kind of group reaction. This has a link
with complexity. Both the system and the agents are responsible for reflexivity. There is no consensus and group reaction all these years in the sector.
33
Collective reflexivity is the concurrent reaction of a group. The system and the agents are responsible for reflexivity.
There is lack of solidarity due to personal ambitions, disinterest and
unwillingness for actions.
34
Collective reflexivity is every action of workers against decisions
that insult their interests. There is a direct relation between
collective reflexivity and complexity. Collective reflexivity is cultivated by groups and the system itself.
Reflexivity is not intensive although the sector experiences rather
sudden changes.
35
Collective reflexivity is the new power of complexity.
The system is responsible for reflexivity. The system is consisted of many
groups.
Healthcare sector cannot survive only through formal rules but also
through deep thinking and ethical regeneration.
36
Collective reflexivity will exist if the system will be rebuilt on new
foundations. Non of them. Something else. Relexivity does not operate effectively or there is no reflexivity.
37
Collective reflexivity appears in anything against the common
sense. Responsibility lies to everyone and reactions are the same
each time. Reflexivity is a way to protect common good and maintain responsibility. Reflexivity works for the benefit of groups and the society.
103

following a
three-pronged approach
monetary change
the issue of stabilisation and how quickly
this could affect the real economy (is
depended on:)
anticyclical monetary
debt management
fiscal adjustments
stabilisation, is the first issue to focus in
the case of a change
the question in the transition phase is how
long this will last for the real economy
this phase is called: "the length of the lag"
the strong relation between monetary
change and economic developments /
business conditions
changes in the stock of money exert an
independent influence on cyclical
fluctuations in economic activity with a lag
that is both long and variable relative to
the average length of such fluctuations
one can seldom get something for nothing in economics
the stability of equilibria: a necessity to achieve
there is no bounce-back resilient practice
but instead bounce-beyond meaning a
change to the bones
the society has to change its structures
and not its roles
the common currency between countries
lead to much lower volumes of trade
especially when they do not create
overvalue through this transaction
therefore, in the long run they tend to look
for markets with different currencies and
variable exchange rates
curiously, neither current account, nor
government budget deficits appear to play
an important role in a typical currency
crash
on the contrary, crashes occur when FDI
inflows dry up, when reserves are low,
when domestic credit growth is high,
when interest rates rise, and when the
real exchange rates shows overvaluation,
and of course when we face sharp
recessions
complexity
CAS: complex implies diversity, a wide
variety of elements/ adaptive means
the capacity to alter or change, the ability
to learn from experience/ system, is a
set of connected-interdependent agents
expectations create new equilibria
the dependence on market expectations
which cannot be finally adhered from
different groups direct to multiplicity
the multiplicity problem is raised by
preferences and constraints of the
different groups plus the government itself
the essence of complexity science is
in the study of patterns and
relationships and in the search of
characteristics of systems far from
equilibrium
complexity science looks not at the parts
but in the wholes and results from the
interactions between the components of a
system
complexity try to explain why there is an
order in the universe although this is
consisted of seemingly unrelated powers
complexity and chaos
complexity science focuses on how order
can emerge from a complex dynamical
system complexity means we have structure with variations
the study of chaos focuses on how
complexity can arise from simplicity
complexity science focuses on
dynamic states that emerge in far from
equilibrium systems
there is the Newtonian perspective which
is a reductionist perspective, where
understanding the whole of a system is
dependent on understanding its parts.
Things must be broken into their
constituent elements in order to
understand them.
run like a clock is the dominant metaphor
this is a mechanistic view of evolving
things, machine-like systems
but healthcare systems demonstrate
different specifications and characteristics
complexity and health-healthcare
it is a challenge to identify the collective
result of nonlinear interactions in the CAS
of health-healthcare
healthcare organisations are complex
adaptive systems and share the
characteristics of CAS
Healthcare organisations as CAS
there are many diverse agents and the
effort to manage such systems of agents
creates major concerns
relationships and interconnections are
critically important
healthcare organisations have the
capacity for self organising and
emergence and they co-evolve
traditional healthcare administration has
been about control
better regulation
financial restrictions
punishment of offenders
healthcare organisations accommodate
unknowability since there are always
under change, self organisation and
emergent properties
managers in healthcare organisations
managers should use complexity to
re-focus attention from creating a better
run organisation to maximise the potential
for the organisation to co-evolve in ways
that increase the organisational fitness
managers are agents in the system and
not external controllers who manipulate
the system with some well thought out
logic
the patterns of interaction between the
manager and other agents in the system
affects the dynamic behaviour of the
system
there is no guarantee though that this
affection will have a predictable outcome
when a manager realises that hc org are
CAS then his focus shifts from knowing
the system to making sense of the
system, from forecasting the future to
prepare to meet the unknowable
future, from controlling the system to
unleashing the system's potential there are three proposed ways for long term success:
being prepared to understand and adapt
to unanticipated consequences
to be ready to respond to emerging opportunities
to implement business practices based on
the nature of CAS
managerial strategies rising
from complexity in
Healthcare
making sense sense-making vs decision making
when facing non linear connections with
emergent properties people in hc should
develop a collective mind about:
what the situation is, who we are, why we
are here, an what is going on around us
the difference between knowing and making sense
sense making requires interaction among agents
sense making enhanced through paying attention
sense making requires agents with:
processing information ability, rule
following ability, ability to connect with
other agents
the characteristics of CAS suggest
heterogeneity as the most fruitful
managerial strategy for enriching sense
making get advantaged from the existed diversity of agents
managers help order emerge in CAS
through sense making but this is not a
stable equilibrium
remembering and
forgetting history
the arrow of time is a key factor and the
non linear trajectory of the system is often
a function of the time-dependent events
that occur
Predisposition is a key factor in both
enabling and inhibiting hc organisational
behaviour
success in the CAS is coming for the
capacity to lean and learning replaces
control as a key managerial function
the most important learning comes from
the trial-an-error action as well as
the reactions taken during this
remembering history is important because
gives examples of how the agents on that
period unfolded their capabilities to learn
and act trying to co-evolve with the
system
it is the capacity to learn rather the
capacity to know the significance
encrypted in a CAS
thinking about the future
traditional planning based on cause-effect
relationships is an inappropriate
managerial strategy in CAS
predicting of future states and feed
forwarding modelling are not useful
scenario planning is a managerial strategy
widely used as this helps an organisation
to deal with surprise
it helps in developing organisational
capabilities for dealing with uncertainty
CAS is about bricolage
being a bricoleur rather than a
traditional manager
bricolaging means creating positive
outcomes from what emerging usually
through confusing and mixed-up
situations
create something out of nothing
Bricolage: to make creative and
resourceful use of whatever
materials are at hand
(regardless of their original
purpose)
CAS maintains capacity to think about the
future through framing the future by social
interaction
CAS are systems of interconnections and
they produce or construct through
co-evolutionary social processes, a
significant part of the environment they
face
dealing with surprise
uncertainty is an essential ingredient of progress
surprise drives progress
innovation depends on a sort of
knowledge no one can gather in a central
place
dealing with surprise requires
improvisational behaviour
improvisation: intuition guiding
action in a spontaneous way
surprise is the constant companion in a CAS
order-chaos-order are phases experiencd in a CAS
loose-tight coupling is an attribute and
status experienced in a CAS
source of surprises in a CAS could be: the
non linear trajectory of the system;
bifurcations; qualitative changes in
behaviour resulting from parameter
changes or sensitivity to initial conditions;
working with ambiguity necessitates improvisation
improvisation recognises the existence of
a basic form of structure where each
player should build upon it using its
instinct, knowledge, risk to further
maintain the development of CAS
taking action
traditional beliefs in HC mean "getting
ready to do it right", while in CAS this is
"taking action as circumstances unfold"
action should focus in small changes that
are expected to provide positive feedback
to the system
small inputs, in general term, provide
more room for learning and organisational
development
in CAS the essence of the system nests
in relationships not in pieces, therefore
the quality of connections is more
important than the quality of anyone
agent
increases in complexity is result of
increases in interdependencies and not
increases in differentiation
an agent's range of influence may be
wide not through the range of interactions
but through overlaps in information
domains
managers should help agents to develop
skills to identify changes in their small
environments
participation in decision making may be a
tactic to resolve healthcare issues, which
brings increased information in the
decision table, creates increased
sense-making capacity and broadens the
organisational actors
unleashing local actors' powers enables
emerging networks that could bring in
return new structures for coping with
surprise
developing mindfulness
traditional mindset on HC implies that
since managers could understand the
cause-effect relationships then
organisations function in an efficient way
the HC system should be understood in
terms of non-linear dynamics,
self-organisation, emergence and
co-evolution
to administer effectively HC systems you
need to develop a stable cognitive
process that will enable CAS to evolve
and operate in a reliable manner; this is
called mindfulness;
mindfulness is the capability to induce
a rich awareness of discriminatory detail
and a capacity for action
to cultivate mindfulness you need a
set of processes to apply continuously:
preoccupation with failure
reluctance to simplify interpretations
sensitivity to operations
commitment to resilience
under-specification of structures
do accept that survival means a struggle for alertness
attention is most important than
information in CAS
observation and mind process are key practices
but...observation as agents of the
system and not as external observers; do
realise that our behaviour is a
fundamental part of the pattern of
non-linear interaction that is causing
emergent behaviour
remember that we do not live in one-world
but in a matrix of co-evolving worlds in
which we must function
in terms of literature and
research we could focus on:
Using complexity as a guide
for acting in Healthcare
proposal for specifying the
dissertation's topic
there is a thought to substitute
"The monetary change" with
"Leaving from a monetary
consortium" but i consider it
slightly provoked.
more focused subject than the
one suggested in the research
proposal
THE CHALLENGE OF STAYING
RESILIENT IN A
TRANSFORMING GLOBE
COMMENTS: we can
keep the literature review
as discussed in the
research proposal, as it
reveals the essence of
complexity starting from
the limits to growth till
geopolitics, economic
geography and shock
effects
the literature review discussed,
actually demonstrates the path
of complexity
the CAS of health care is
interconnected with the CAS
defined by geopolitics, limits to
growth etc
in terms of specifying the
scope of the dissertation we
proceed the review and the
application of research tools
towards the concrete subject
Keune, Hans (2012)
Critical Complexity in
environmental health
practice: simplify and
complexify. Journal of
Environmental Health , 11
(Suppl 1): S19, p. 1-10
Easton, D and Solow, L
(2011) Navigating the
Complexity Space.
Proceedings of
International Conference
on Complex Science , 15
June 2011, p. 665-677
Begun, W. James et al
(2003) Health Care
Organizations as Complex
Adaptive Systems.
Journal of Advances in
Health Care Organization
Theory, p. 253-288
McDaniel, R. Reuben and
Driebe, J. Dean (2001)
Complexity Science and
Health Care
Management. Journal of
Advances in Health Care
Management, 2, p. 11-36.
Psychogios. A (2011)
Understanding
Organisational chaos and
Complexity. Leading &
Managing People
Executive MBA Course
Lectures
Zimmerman, Brenda et al
(1998) A Complexity
Science Primer.
Edgeware: Lessons from
Complexity Science for
Healthcare Managers .
Specify_the_Dissertation_scope.mmap - 11/9/2012 - Evangelos Ergen

HISTORY
complex systems have a history which
cannot be ignored
Temporality: complex systems
echo their history, their memory of the
past in a selective, non-linear manner
NESTED SYSTEMS
complex systems are nested systems
the components of the system are
themselves complex systems
NO BOUNDARIES
boundaries of the system is difficult to be
determined since any attempt may raise
ambiguities
MICRO-DIVERSITY
the importance of local; what happens to
an agent depends on the response of
other agents at a particular place
DIVERSITY
THERE IS NO CENTRAL CONTROLLER
Non-linearity: due to partly
non-linear input-output functions, complex
systems will show unpredictable
behaviour
UNPREDICTABILITY
the problematic issue of Reduction
any knowledge we have about the system
is a reduction of its complexity
reduction=micrograph
reduction=simplification
there is a hidden power in CAS
and this is its ability to: allow a massively
entangled group of diverse individual
agents the freedom to be adaptable and
resilient
this is considered the main motive for
self-organisation and self-preservation of
the CAS
CASs are dynamic, massively entangled,
emergent and robust
CO-EVOLUTION
when CAS self organises and emerges in
a dynamic fashion, this also affects the
world around CAS
co-evolution means that each change in
CAS fundamentally influences its
environment and vice versa
agents do not simply adapt and interact,
they co-evolve with the environment in a
constant ambient of change
e.g. when a hospital changes the control
system of pharmaceutical supplying, this
affects its relationship with
pharmaceutical providers, and this affects
possible competitive advantages, even
business models etc.
there will always be an agent who will
pose new patterns and introduce new
methods in a way that this will change the
overall environment and simply impose
other agents to adapt and co-evolve
co-evolution encrypts the function of
placement and repositioning ,
since each agent tries to place itself in the
new framework
repositioning is necessary for the agents
to find their fitness landscape
Healthcare systems are constantly
attempting to improve their functioning
through seeking new places of
competitive advantage on their fitness
landscape
nevertheless, its difficult to find the fitness
landscape since no agent has the big
picture of CAS
co-evolution limits the developmental
processes in a CAS since agents posses
conflicting constraints with other agents
compromise and cooperation may lead to
a workable solution
the structure of a system is not a result of
an a priori design rather than a result of
interaction between the system and its
environment
real organisms constantly circle and
chase each other in an infinitely complex
dance of co-evolution
SELF-ORGANIZATION
this is the spontaneous emergence of
new structures and new forms of
behaviour in CAS
arise from the changing patterns of
relationships in CAS
self organisation usually describes the
situation where new emergent properties
may arise without being imposed
there exists a self-organising behaviour
nevertheless, more tightly coupled
structures tend to lock-in to a certain
response
many changes depend on the nature of
structure of the agents and the CAS
resilience usually derives from a
robust response in the effort to adapt
to a wide range of environmental change
the structure and form of CAS is a
function of patterns of relationships
among agents and interactions of these
agents with their environment
CAS has distributed control rather than
centralised control
there is no central body that controls CAS
CASs are robust or fit, since they
exhibit the ability to alter themselves in
response to feedback moreover, they are dynamic depending on their motives
in the complex systems approach the
order is not only the sum of individual
intentions but the collective result of
nonlinear interactions
also order in the system may be the result
of the properties of the system itself
self organisation is linked to order and the
capacity of self organisation is the
function of the number of connections
among agents and the intensity of these
connections
it is not true that the more connections the better
on the contrary, too many connections
may lead to behaviour that never settles
into any recognizable pattern of self
organisation
on the other hand, too few connections
may lead to frozen behaviour rather than
dynamical self organisation
CAS consist of agents, interconnected,
generating order
the conditions for self-regulation happen
when agents decide to shift and change
both internally and externally affecting
each other
AGENTS
agents are information processors
agents process information and react to changes
they exchange information between
themselves and with the environment
agents have different information about the system
they can adjust their behaviour
they are acting and reacting to what other agents are doing
agents are diverse from each other
nevertheless, this diversity among agents
can be a source of frustration
e.g. in healthcare the accounting
processes could be in conflict with healing
processes
agents select with whom and how they will interact
diversity is the source of novelty and adaptability
additionally could be the source of
invention and improvisation
none of the agents can understand the
system as a whole
this consists the bottom line of complexity
if an agent could perceive the system as
a whole then he would accommodate all
the complexity on his own
there is no any central agent who could
manipulate the system
each agent pays attention to its local environment
the agents in a complex system cannot
know what is happening in the system as
a whole
agents are the central actors in abstract
models of CASs
BUILDING BLOCKS
agents at any one level in a CAS serve as
building blocks for agents at a higher level
different agents take different roles as the
dynamic of the CAS unfolds
CAS are constantly revising and
rearranging thei building blocks as they
gain experience
as building blocks change over time the
whole system/organisation changes
CAS consist of agents who act and react
based on self-generated stimuli, and the
actions of other agents from either inside
or outside the system
agents demonstrate a dynamic state
CAS are made of a
large number of agents
INTERCONNECTIONS (the
essence of connectedness)
the essence of CAS is captured in the
relationships among agents
as a result in a CAS, there may be many
interdependent agents who interact with
each other in many ways
the dynamics of these interactions makes
CAS qualitatively different from static
complicated systems
to understand a CAS it is necessary to
understand the patterns of
relationships among agents and not
simply their nature
e.g the personal relationship between the
patient and the physician is a significant
moderating factor
e.g the relationship among the clinical
staff is critical to the overall performance
of the organisation
e.g failure to resolve relationships
problems is the major cause of difficulty to
apply any progress in the health system
such as information technology practices,
tele-medicine etc
relationships among agents are
complicated and enmeshedmassively entangled
the environment of the agents is the
function of interconnections that each
agent has with other agents in the system
and with agents in the system's
environment
it is not simply the number of connections
that determines the character of a CAS,
but the richness of these
connections
relationships among agents are non-linear
inputs are not proportional to outputs
a small stimulus may cause a large effect
or no effect at all
actions and behaviours of small
non-average groups may result in
unintended consequences
small changes can lead to big effects and
big changes can lead to small effects
simple deterministic equations may
produce an unsuspected richness and
variety of behaviour
complex and chaotic behaviour can give
rise to ordered structures
relationships are short-range mostly
received from near neighbours
another issue, except the range of
interaction is the range of
influence of an agent to the others
information that is carried out through
feedback mechanisms create patterns
of interaction
interactions may be pooled, sequential or
reciprocal and define the level of
adaptability of CAS
both positive and negative feedback are
key ingredients of the relationship and the
system itself
the different interactions as derived
among agents' interconnection create
patterns of interconnection and in
turn introduce non-linearity in the
dynamics of the system
such patterns of interconnection can
follow simple rules and complex
behaviour can emerge from these
rules
CASs tend to maintain in general
bounded behaviour , called an
attractor, regardless os small changes
in initial conditions
interconnections among agents define the
width of complexity
complex systems are open exchanging
energy and information
EMERGENCE
emergence is a product of
context-dependent non-linear interactions
agents interacting in a non linear fashion
may self organise and cause system
properties to emerge
individual agents do not know the
behaviour of the whole system and
they cannot control emergence of the
system
emergence is the source of novelty
and surprise in CAS
CAS demonstrates sensitivity to certain
small changes in initial conditions
(butterfly effect)
nevertheless, this sensitivity has to do
with the exact path that the complex
system follows in the future, rather than
its general pattern
the properties of the whole system are
distinctly different from the properties of
the parts
it comes from the presence of a great
number (often simple) of system
components that interact in a manner that
cannot be explained by the characteristics
of individual components
organisational mergers and their issues
need to be viewed through the complexity
perspective in order to detect their
emerging properties
emergence rises from the pattern of
connections among diverse agents
but it is more than connectivity
e.g the quality of a surgical team is the
properties and the talents of the individual
medicals but it is not reducible to this
it is an emergent property of the whole unit
emergence is a repeating attribute in a
CAS since there are emergent structures
and agents which in result modify the self
organising characteristics of CAS
emergent order is always changing in
unpredictable way
emergence is mostly related to the
generation of new properties at the macro
level of analysis as a result of non linear
dynamics
some behaviours and patterns emerge in
complex systems as a result of the
patterns of relationships between the
elements
the existence of building-blocks is
crucial since, when constrained by simple
rules can generate an unbounded stream
of complex patterns
(2003) Health Care
Adaptive Systems.
Theory, p. 253-288
Keune, Hans (2012)
Environmental Health , 11
(Suppl 1): S19, p. 1-10
Easton, D and Solow, L
(2011) Navigating the
Complexity Space.
Proceedings of
International Conference
on Complex Science , 15
June 2011, p. 665-677
Psychogios. A (2011)
Understanding
Organisational chaos and
Complexity. Leading &
Managing People
Executive MBA Course
Lectures
Health Care
Management, 2, p. 11-36.
CharacteristicsOfComplexAdaptiveSystems.mmap - 11/7/2012 - Evangelos ERGEN

Special
characteristics
of health care
organizations/sector
there is significant
information asymmetry
among agents, especially between
clinician providers of services and
typical patients
such asymmetries create
interdependencies
there is a weak link between
service recipients and service
payers
this weakness leads to potential
distortions of system's characteristics
there is a considerable technological
and professional
heterogeneity within any health care
organization
this increases the difficulty of
understanding the organization and the
system as a whole
there is even heterogeneity between the
agents of the same system
e.g. two agents may approach the same
problem in a different way and with
different resources (the issue of vision
problems in ageing population) and how
differently this is confronted by Public
Health and Ageing Networks
relationships is the central
component to understand the
system
the behavior of the system is the result of
the interaction among the agents
highly competent professionals with poor
interaction obviously could not provide
good care
generative relationships
actions are based on
internalized simple rules and
mental models
in human level the rules can be
expressed as instincts, constructs and
mental models
attractor patterns is the
response of the system to certain
issues of change e.g. desire for
autonomy
the paradox of: from the one side to adapt in
changes in the one part of the health care system, while
on the other side another part of the system
demonstrates a remarkable resilience maintaining the
status quo
experimentation and
pruning: health care systems
need to experiment new ways of
doing things
inherent non-linearity
it is difficult to predict in the health care
system where are the non-linear change
points for the system
systems are embedded within
other systems and co-evolve
a medical group is a complex system
embedded in a regional health care
system embedded in a national health
care system embedded in a political
system
the most challenging complex field
of today is: the relationship
between environment
and health
the most complex systems are social
systems and healthcare organisations are
the most complex within that subdomain
contexts and
relationships are usually ignored
or marginalised in economic evaluation in
healthcare
healthcare organizations demand
to be approached under
non-linearity and
emergence in terms of
management (they are living
organisms and not mechanistic
systems)
there are patterns and relationships
among the parts of the system which are
often unrecognized or even invisible
there are actions on behalf of unpredictive
humans which often emerge without
authority
systems and subsystems that exist in a
far-from-equilibrium state and are never
wholly stable
it is a matter of how we
conceptualize such
organizations
Resilience fits the
complexities of healthcare more
effectively than principles of high
reliability
resilience moves the focus away from
"what went wrong" to "why does it go
right"
it gives an emphasis on the proactive
focus on error recovery
resilience provides the framework to learn
and adapt in an environment that is
fraught with gaps, hazards, trade-offs and
multiple goals, as well as coping with
erratic people
there is a "new view of human error"
which sees humans in a system as a
primary source of resilience
Complexity thinking in
healthcare is an embedded
characteristic of the sector
tradeoffs across multiple objectives
perspectives of different stakeholders
...and all these are strictly connected with
decisions on human lives, quality-of-life
and health on human capital
as a result healthcare needs to deal with
complex social problems with multiple
factors mediated by individual and social
contexts
economic evaluation in healthcare should
take into consideration complexity and
assess reflexivity
changes can only happen through critical
thinking and epistemological
collective reflexivity
quantitative methods are not adequate to
evaluate healthcare in economic
evaluations
the socioeconomic position of a region,
ethnicity, has a straight impact on its
health status
the impact of learning to live or not with
complexity demonstrates broader aspects
of concern such as: ethnical and regional
inequalities, as a result of poor
socioeconomic positions, which in extent
form the regional human capital and its
worthiness in the global terrain depending
on its health status
when a system has as its primary working
parts human beings then these have the
freedom and ability to respond to
stimuli in many different and
unpredictable ways
changing the ethical climate
of healthcare sector places in
danger the region
cost constraint and quality improvement
cannot co-exist in the sector
placing sales techniques and market
solutions in healthcare changes the
nature of healthcare more like a market
commodity rather than a social service
therefore, it is crucial how we administer
controlling cost strategies as well as the
measures that we use to manage the
service cycle for patients
healthcare sector needs
governance ethics rules
which will be the compass for its
operation
Plsek, Paul et al (2003) Complexity and the
Adoption of Innovation in Health Care. Proceedings
of Conference in Accelerating Quality Improvement
in Health Care Strategies to Speed the Diffusion of
Evidence-Based Innovations , January 27-28, 2003
(2003) Health Care
Adaptive Systems.
Theory, p. 253-288
Easton, D and Solow, L (2011)
Navigating the Complexity Space.
Proceedings of International Conference
on Complex Science , 15 June 2011, p.
665-677
Jeffcott, S.A. et al (2009) Resilience in
Healthcare and clinical handover. Journal
of Quality and Safety in Healthcare , 18, p.
256-260
Lessard, Chantale (2007) Complexity
and Reflexivity: Two important issues for
economic evaluation in healthcare.
Journal of Social Science & Medicine ,
64, p. 1754-1765
Davey, Smith George (2000) Learning
to Live With Complexity: Ethnicity,
Socioeconomic Position, and Health in
Britain and the United States. American
Journal of Public Health , 90(11), p.
1694-1698
Mills, E. Ann et al (2003) Complexity
and the Role of Ethics in Healthcare.
Journal of Emergence , 5(3), p. 6-21
Health Care
Management, 2, p. 11-36.Keune, Hans (2012)
Environmental Health, 11
(Suppl 1): S19, p. 1-10
Orr, L. Alberta et al (2006) The Complexities and
Connectedness of the Public Health and Ageing
Networks. Journal of Visual Impairment &
Blindness, Special Supplement, p. 874-877
SpecialCharacteristicsof_HC_CAS.mmap - 10/28/2012 - Evangelos ERGEN

Research
Questions
Framework
Interview questionnaire (English
version) Interview questionnaire (Greek version) 1st interview questionnaire 2nd interview questionnaire 3rd interview questionnaire 4th interview questionnaire 5th interview questionnaire 6th interview questionnaire 7th interview questionnaire 8th interview questionnaire 9th interview questionnaire 10th interview questionnaire 11th interview questionnaire 12th interview questionnaire 13th interview questionnaire 14th interview questionnaire
15th interview questionnaire (handed
empty)
1
Who are the players/agents in the
Greek healthcare system?
Ποιές είναι οι ομάδες που απαρτίζουν το
σύστημα υγείας της χώρας μας? (π.χ.
γιατροί, νοσηλευτές, φαρμακευτικές
εταιρείες κλπ). Παρακαλώ καταγράψτε
όσες ομάδες νομίζετε ότι συμμετέχουν.
Doctors, Nursing staff, Pharmacists,
Pharmaceutical companies, Paramedics.
Medical Doctors, Nursing staff, Lab
Doctors, Healthcare Administrative
Services, Paramedical staff, Supportive
staff (assistants, cleaning services, cooking
services, safety and technical support).
Doctors, administrative staff, nursing staff,
technical and support staff (e.g. Computer
department).
President of Hospital, Directors of
Departments, Nursing staff, Medical
doctors, Paramedical staff, Administrative
staff.
Doctors, Nursing staff, Therapists, other
Health professionals, Technical lab staff,
Technical assistants, Administrative staff.
Doctors, pharmaceutical companies
(medical and pharmaceutical visitors
salesmen), pharmacists.
Doctors, nurses, pharmacists, technical
staff, lab assistants.
Doctors, dental doctors, nursing staff,
other medical staff, social workers.
Doctors, Administration, Pharmaceutical
companies, Nursing staff, Political parties
and Government, Patients, Administrative
support.
Doctors, nursing staff, paramedical staff,
technical staff, administrative staff.
Doctors, nursing staff, technical staff of
labs, social workers, administrative staff,
cleaning and other suportive staff (drivers,
workers etc), employees in information
management office.
Doctors, nursing staff, pharmacists,
administrative staff, supportive staff in
hospitals, paramedical staff, technical
services and technicians.
Pharmacists, therapists, doctors,
administrative staf, nursing staff,
paramedicals, technical staff.
administrative staff, Ministry of Health.
2
Can you prioritise them according to
their power in regards to healthcare
services supply chain? Who are the
agents that play the primary role?
Μπορείτε να τις χωρίσετε σε κατηγορίες
ανάλογα με την δυναμική τους στον
κλάδο? Ποιές/Ποιά είναι η
ισχυρότερη/ες? Ποιές κατά την άποψη
σας παίζουν πρωταρχικό ρόλο στις
τρέχουσες αλλαγές που
πραγματοποιούνται στην χώρα?
1. Doctors, 2. Pharmacists, 3. Pharmaceutical
companies and 4. European Union Directives.
1. Healthcare Administration, 2. Doctors,
3. Nursing staff, 4. other administrative
supporting services (law services).
1. Computer staff, 2. Doctors, 3. Nursing
staff, 4. Administrative, 5. Technical staff.
1. President of Hospital, 2. Director of
Nursing staff, 3. President of Union.
1. Doctors, 2. Nursing staff, 3.
Administrative‐Technical staff. 1. Doctors, 2. Pharmacists. 1. Doctors, 2. Nursing staff.
1. Doctors who hold and administrative
positions, 2. University doctors, 3. Doctors,
member in unions, 4. Doctors in
pharmaceutical companies, 5. Nursing
staff.
1. Doctors, 2. Government, 3.
Administration 1. Doctors 1. Doctors, 2. Nursing staff
1. Doctors, 2. Paramedical staff, 3. Nursing
staff, 4. Administrative staff.
1. Doctors, 2. Nursing staff, 3.
Paramedicals, 4. Administratives, 5.
Technical assistants.
1. Doctors / this is the most important
group which plays crucial role in current
changes of the system as well.
3
Who has inside information due to
current structure? Can this change?
What is necessary to do in order to
restrain information asymmetry?
Ζούμε στην εποχή της πληροφορίας.
Ποιά/Ποιές ομάδες πιστεύετε ότι
διαμορφώνουν την πληροφορία?
Ποιά/Ποιές έχουν ενδεχομένως
προνομιακή πρόσβαση? Υπάρχουν
μονοπωλιακά φαινόμενα στον κλάδο?
Μπορεί η χρήση τεχνολογίας να βελτιώσει
την διαχείριση της πληροφόρησης για το
καλό όλων?
Information is formed by the above 3 first
categories plus nursing staff. Information is
diffused in a monopolistic way and through
definite channels. Nevertheless more use of
technology can affect and change this
phenomenon.
Information is formed by nursing staff,
doctors and administratives in healthcare.
I cannot say if someone has specifically
more inside information, may be the
administratives but it is not clear. There is
not monopolistic use in the sector though,
but more technology definitely is expected
to help more the sector.
People that have mainly access in
information is the administrative
Computer people who have access in data
and information. It is true that such people
have more and direct access.
Nevertheless, i do not know if this creates
monopolistic status. The more use of
technology will make situations more
controllable and sharing.
Technology can help in general terms, but
can also create problems. Information is
provided by the Ministry of Health and its
staff.
All groups have inside information and
define information in a sense, but each
group process the information owns
seperately and differently.
The groups that are more familiar to
technology are the younger people,
although the biggest market of healthcare
is the older ones.
Information is defined by all groups
equally and all have access to it. There are
monopolistic phenomena but more
technology can help in balancing such
occassions.
Information is defined mainly by political
staff and medical staff. The increasing use
of technology helps in the elimination of
monopolistic situations. The management
of information is not necessarily always
effective and helpful.
Inside information have the doctors,
pharmaceutical companies, patients and
the administration. The use of technology
can change and improve the
administration of information.
Inside information is controlled by doctors
and technical staff who have access in
information.
There were some monopolistic
phenomena of inside information but now
this has changed due to increasing use of
technology. Now, anyone who interest can
find the information.
Doctors and pharmaceutical companies
have inside information and they form the
information for the others. There are still
monopolistic phenomena. Technology may
help in improving the information
administration.
All involved groups have some kind of
inside information. Technology can
definitely improve the information
administration.
Doctors has inside information and they
are responsible for the formation and
administration of information. They are
responsible for the monopolistic
phenomena which could be eliminated if
technology penetrates.
4
How important are the relations among
agents in healthcare? Do relations play
a decisive role for the system? Is this
positive, negative, neutral?
Υπάρχουν σχέσεις αλληλεξάρτησης
μεταξύ ομάδων στον τομέα της υγείας
στην χώρα μας? Πόσο σημαντικές είναι
αυτές και πόσο επηρεάζουν την
λειτουργία της υγείας? Ανάλογες σχέσεις
μπορεί να συμβάλλουν θετικά ή αρνητικά
σε οποιεσδήποτε εξελίξεις?
There are strong relationships among agents
in healthcare, such as: (doctors‐nursing staff,
doctors‐pharmacists, doctors‐pharmaceutical
companies). These relations are significant
for the healtcare operation. They might have
either positive or negative effect.
Yes, there are relations among agents
which affect healthcare operations. Might
be positive and negative at the same time.
It is true that there are relations among
groups. It is imperative for all services to
operate in a correct manner to gain
results. Otherwise this cannot be achieved.
There are relations among agents which
can affect healthcare either positive or
negative.
are considered very important. These do
play a significant role in the system.
There are interelations among agents.
These days that the system is in transition,
still doctors have the full power since they
decide which drug to give in the patient.
Although the system is on‐line, doctors
define which medicines will be given and
patients do not have the option to buy
substance instead of a given brand.
Relations among agents are very
important. These must exist since they
help in the advancement of healthcare as
service and science.
There are relations among agents. Such
relations are obvious on daily practice, but
when there are problems in collective
level, these does not necessarily work.
Cooperation among agent is too difficult
and this does not help the sector.
There are relations among agents, which
are considered very significant. Such
relations can affect either positive or
negative.
There clear relations among agents and
these raise positive contribution to the
system.
The relations among agents are very
important as long as these are acting as
groups and not as leaders who would like
to stratify people into leaders and
followers. Healthcare is affected negative
whenever groups are not acting as real
groups. Therefore, there is a need for
consensus and link which will act
positively.
There are relations among agents, which
are very decisive in affecting healthcare
services. Such relations may raise positive
or negative effects.
Relations exist among agents and these
are very important.
There are relations among groups for
example doctors with nursing staff, these
are very significant and play crucial role in
the sector.
5
Who defines the relations patterns in
the system? Who is responsible for the
relations; the system, the building
blocks of agents?
Ποιός καθορίζει τις σχέσεις
αλληλεξάρτησης? Κάποια ομάδα,
συνδυασμός ομάδων, μήπως το σύστημα
το ίδιο λόγω της οργάνωσης του?
Responsible for the definition of relations
patterns is the system. The way that this is
organised creates such distortions.
Relations patterns are defined by the Law
and Institutional framework in general. In
continuous, agents‐groups and the system
are responsible for the application.
system itself and they way this is
organised.
system.
Relations patterns are defined by
everyone, every group and the system
itself.
system which is badly organised.
The system is responsible for the patterns
of relations.
The system imposes the relations patterns.
Sometimes responsible for the relations
are the leaders of the groups who act on
behalf of other motives. The system
demands the groups to work
independently in order to avoid further
correlations, but this is not feasible in the
end.
system itself. The interdependencies
developed are mutual for all groups in the
system.
The relations patters are defined by the
healthcare system.
The relations patterns are defined both by
the groups and the system in combination
with knowledge and common interest
towards better services to patients. The
system due to inadequacies is an obstacle
in any development.
system itself.
Relations patterns are defined by a group
of groups.
system.
6
Do relations create interdependencies?
Does this create paradoxes in the
system? Does this reveal weaknesses?
Μπορεί μια σχέση αλληλεξάρτησης να
δημιουργήσει παραδοξότητες ή να
επιφέρει στρεβλώσεις?
Since the system is organised in a rather
paradoxical way it is inevitable to avoid
distrortions and unbalanced relations.
Yes, relations may create
interdpendencies.
Interdependencies are not necessarily
negative. If they do not operate in a
correct manner this of course may raise
paradoxes and create weaknesses.
Relations do create interdependencies
which in continuous create paradoxes and
distortions.
Interdependencies create paradoxes and
generate different perceptions about
information and other characteristics in
the sector.
Relations create interdependencies as a
natural outcome of the system's setup.
Nevertheless, such closed relations could
be avoided by placing boundaries.
Relations create interdependencies and
such a characteristic creates paradoxes in
the system. It may create distortions and
reveal weaknesses.
Relations create interedependencies and
may direct even in the change of
management and people in charge.
Interdependencies create distortions and
paradoxes. Relations create interdependencies.
Interdepedencies are not negative as long
as there exists the common knowledge of
intersupport and mutual respect among
members. The good organising,
programming and consensus does not
bring paradoxes in the system.
Interdependencies as a result of relations
patterns followed, create paradoxes and
distortions. Relations do create interdependencies. Relations create interdependencies.
7
What is the real nature of
interdependencies? Do they enable or
block emergence and self‐
organisation?
Μπορούν αυτές οι σχέσεις να
προκαλέσουν αλλαγές στο σύστημα?
Μπορούν να βοηθήσουν στην
απελευθέρωση νέων υγιών δυνάμεων?
Μπορούν να οδηγήσουν σε μια νέα αυτο‐
οργάνωση?
Only changes in relations patterns could
enable changes in the system.
Relations cannot create changes in the
system. They can help though the release
of new powers and they can help in a new
self‐organisation.
There happen new attempts for the
improvement of relations and the
interdependencies existed. The
introduction of new technologies is
expected to alter and help current
situation towards emergence and self‐
organisation.
Interdependencies could be positive and
could help in unleash of new powers
towards self‐organisation.
Such relations can direct to unleash of new
powers and self‐organisation.
Interdependencies could be proved
beneficial for the system. For example
these could be direct to the decrease of
pharmaceutical spending and
improvement of relations among doctors‐
patients.
Real interdependencies could direct in
new organisation, through generation of
new powers.
Interdependencies serve internal purposes
for the system. They could enable
emergence but this requires change of
mentality as well. Interdependencies
cannot help positively unless there is
cooperation among agents, exchange of
ideas, common perspectives and
willingness to succeed. All these are too
difficult to take place in the sector.
Interdependencies enable emergence and
self‐organisation especially in the case of a
clear, balanced and mutual benefit
cooperation among groups in the sector.
Interdependencies help in revealing new
powers and may direct to self‐
organisation.
Real interdpendencies bring new powers
and changes in the system, along with
better results. Self‐organisation requires
better schooling to be effective. Interdependencies can reveal new powers.
Interdependencies can direct to new
structures and self‐organisation.
Such relations and interdependencies
could cause changes in the system. They
could lead to a new self‐organisation as
well.
8
What is heterogeneity in healthcare?
Στο σύστημα υγείας συμμετέχουν
διάφορες ομάδες? Υπάρχει
διαφορετικότητα μεταξύ των ομάδων,
παρόλο τους κοινούς στόχους που
ενδεχομένως έχουν? Εάν υπάρχει
διαφορετικότητα, πόσο ευρεία είναι
αυτή?
There is heterogeneity in the participative
agents and this is the main cause for the
deviation from the common target which is
providing good healthcare services.
There are differentated groups in
healthcare and there is heterogeneity
among them. This differentiation is rather
wide in terms of different approaches in
the sector.
There is diversity and in extent
heterogeneity in healthcare. Different
groups are participating.
There is heterogeneity in Greek healthcare
sector which demonstrates rather a wide
range.
Heterogeneity is the normal result of the
different targets that each group has in the
sector. For example: Doctors and nursing
staff have same targets which in the same
time are different from administrative and
technical staff. Different groups, different
targets.
There exists heterogeneity in the Greek
system, but most of the times this is not
accepted. As a result diversity means
minority.
There is diversity in the sector and it is
wide.
Heterogeneity in healthcare is the
difference among agents in various areas
such as knowledge, expertise, tasks,
nature of job itself. There is much
difference but common elements are
many and all groups in healthcare have
things that unite them.
Heterogeneity exists in terms of
rewarding, personal interest, specialised
duties. Such characteristics create
contradicted relations.
There is no real heterogeneity among
groups in healthcare sector.
Heterogeneity in healthcare stems from
the different professions that exist in
healthcare. Heterogeneity is cultivated
through education most of the times but
through years is eliminated through
experience.
Heterogeneity is the phenomenon of the
existence of different groups in the
system. This heterogeneity is wide in
healthcare.
There is heterogeneity in healthcare, and
this is due to the different objectives of
the groups. Nevertheless, they have
common targets in the frame of
healthcare.
Heterogeneity exists and mostly refers to
development and financial decisions.
9
Where and how this is identified? What
kind of problems does this create?
Σε ποιούς χώρους του τομέα, μπορούμε
να διαπιστώσουμε εάν υπάρχει
διαφορετικότητα? Εάν τελικά υπάρχει
διαφορετικότητα, αποτελεί αυτό
πρόβλημα για την χώρα?
This could be observed mostly in nursing
area and the pharmaceutical care provision.
Especially in these two areas heterogeneity is
a problem for healthcare.
The areas of medical doctors is a suitable
area to identify this diversity. This is more
obvious in hospitals and within
administrative services. Referring to
hospitals we may include Health Centers
of the country (Kentra Ygeias), Peripheral
Medical Units and Hospital across country.
This diversity becomes a problem for the
sector.
Heterogeneity and diversity could be
observed mostly in medical and
administrative staff as well as in nursing
staff. The differences among these groups
creates problems in healthcare and
especially in the operation of hospitals.
Heterogeneity is not a problem, since
different groups have different actions
because off the different objectives.
Diversity and heterogeneity could be
observed in many places and is rather a
problem, not only for the sector but for
the country as well.
Diversity and difference usually create
problems in communication and
understanding between people. This is
more obvious when one group cannot
understand the problems of the other
group. In a complex system this weakness,
isolates the groups and they cannot see
the benefit for the whole system.
Heterogeneity exists in all areas of the
sector. This can be a problem for the
country unless there exists a framework of
common principles accepted and applied
from everyone.
Heterogeneity does not exist and does not
create any problems in the healthcare
system of the country.
Hererogeneity is everywhere and usually
does create problems.
Heterogeneity exist mainly in medical and
paramedical areas, but it does not consist
a problem for the country unless it affects
the cooperation of groups.
Heterogeneity is mostly identified in
administrative sector.
Hererogeneity could be better identified in
hospitals.
Interviews' results first registrationInformatonAsymmetryInterdependenciesHeterogeneity

10
Can heterogeneity be a source for
development?
Πιστεύετε ότι η διαφορετικότητα μπορεί
να είναι πηγή εξέλιξης?
Heterogeneity could be, in general, a source
of development for the sector.
Heterogeneity and diversity could be a
source of development but could become
also a brake in any kind of evolution for
the sector.
Diversity and heterogeneity could not be a
source of development.
Heterogeneity and diversity can be a
Heterogeneity could be a source of
development.
Heterogeneity can only be a source of
development if groups can find common
ground to meet and discuss. Only in this
situation pluralistic approaches could be
beneficial for all and each group will
realise that emphasis should be given in
strong points rather than weaknesses.
Diversity could be a source of
development.
Real heterogeneity and diversity, if exist,
can be source of evolvement.
By itself cannot be a source of
development, but it can be in combination
with other factors.
Heterogeneity may be a source of
development. It can be source of development.
Yes, heterogeneity can be a source of
development.
11
What is an attractor pattern? Who is an
attractor in the current healthcare
system in the country?
Ποιοί καθορίζανε και καθορίζουν τα
πρότυπα συμπεριφοράς μέσα στο
σύστημα υγείας της χώρας μας?
Firstly, the Law framework, but since there is
absence of control, reporting and evaluation,
such patterns are defined by personal or
agents' interests.
Attractor patterns are defined by the
informal institution's framework, the
informal professional organisations, trade
unions,  and social prejudices.
Attractor patterns are the Ministry of
Health and the Law framework. These
groups direct patterns of behaviour.
The main attractor in the healthcare
system is the Public Code of Professional
Ethics for the employees in the sector.
The attractors in the system are all agents
themselves. The system defines the
Professional Codes of Ethics, but groups
implement them or not.
system and its organisation. In continuous
this is exploited by groups such as doctors,
pharmacists, companies etc. When there is
no control and measurement in a system
then there is no punishment and decay.
All agents that participate in the system
are attractors and contribute in the
formation of attractor patterns.
Attractor patterns and patterns of
behaviour are defined by the educational
system of the country. Especially
University education and the mentality of
academic professors play a significant role
in the perception of healthcare system.
For example, the traditional view about
the doctors' status in the system.
Attractor patterns are not specific groups
or persons rather than our mindset,
cultural approaches, job environment and
personal interests.
Pharmaceutical and medical companies
are the attractor patterns who additionally
define the behavioural patterns in the
system.
Attractor patters are generated over the
system's weaknesses. Wherever there is a
gap there is something new born. And this
was a mistake so far.
Attractor patterns are affected by our
education system and administration
which cultivates this system.
Attractor is the Ministry of Health for the
system in Greece. Doctors are attractors in the system.
12
How these patterns work in the
system? Do these impose contexts? Is
this possible for a new attractor to
emerge from changes in structures?
Πως λειτούργησαν και λειτουργούν τα
πρότυπα συμπεριφοράς όσο αναφορά την
εξέλιξη του συστήματος? Μπορούν τα
πρότυπα συμπεριφοράς να αλλάξουν σε
ένα νέο σύστημα οργάνωσης?
Attractor patterns plays a crucial role in the
system's evolution. I consider that these
patterns will not change easily in a possible
change of the system.
Existed attractor patterns have been
negative for healthcare and it is imposed
to be changed.
In general terms these patterns of
behaviour worked positively. If the system
changes the patterns of behaviour will
change as well.
Patterns of behaviour should be followed
from everyone. They could change in a
new system.
Patterns of behaviour may change in a
new system.
Patterns of behaviour operate both
negative and positive. They can affect and
change the system towards new
structures.
Attractor patterns does not help the
evolvement of system, but they maintain it
in the same position. A new system
demands new patterns. The challenge is to
create a new system based on existed
patterns but adapted to new needs and
new targets. To copy patterns from others
is not useful.
Patterns of behaviour can change the
system. But this demands time since the
prerequisite is to introduce and accept
first new prototypes.
Behavioural patterns and attractor
patterns operate in terms and towards
profit making. This target, defines
behaviours and development in the
system.
Current attractor patterns do create
problems. But these can contribute in
changing structures.
Behavioural patterns were affected by
attractor patterns in a monopolistic and
backward way for the system.
Attractor patterns can enable changes and
can impose contects.
Attractors form patterns for their own
benefit. As a result they may either block
or help changes in structures.
13
Can the system work without
attractors? When/Under which
circumstances attractors take
responsibility and protect the system?
Θα μπορούσε ένα καινούριο σύστημα
υγείας να προοδεύσει βασιζόμενο στις
υπάρχουσες και παλιές δυνάμεις του? Θα
μπορούσε να αντέξει τις έντονες
μεταβάσεις στην νέα αυτο‐οργάνωση? Ή
θα ήταν καλύτερο να διαλυθεί και να
ξαναχτιστεί σε νέα θεμέλια?
It is impossible to destroy and re‐build the
healthcare system of the country. There
must take place radical changes based on
existed and new powers.
I consider that the system should be re‐
established.
The new system should be based in
current and older powers to rebuild using
attractors and trying to overpass previous
distortions. We do not need another
catastrophy.
The system cannot work without
attractors. Healthcare should be re‐built
but with the exploitation of older powers.
Nevertheless, the characteristic that
should be changed is mentality.
The rules have to change, the operational
processes have to change, the
Management of hospitals need to change.
The old system should be kept and be re‐
structured.
The system should be destroyed and
rebuilt from scratch based on new axes.
The system cannot work without atractors.
It would be ideal to destroy the system
and build it from the beginning but this is
unrealistic. Unavoidably we should follow
a transition stage where older powers will
mix with newer and together will lead
changes.
The new system could be born from the
old one, could be rebuilt, could be
regenerated, but not destroyed. The system should be rebuilt from scratch.
The system should restructure itself using
old and new powers as much as possible.
The system should be destroyed first. Then
we should built on new foundations.
The system should be built on new
foundations.
attractors and should be built on older and
new powers.
14
What are generative relationships and
what is the difference with
relationships as discussed earlier?
Εκτός από τις ευρύτερες σχέσεις
αλληλεξάρτησης, υπάρχουν και
ειδικότερες σχέσεις προστασίας και
αλληλοβοήθειας μεταξύ ομάδων μέσα
στον τομέα υγείας. Αυτό είναι ένα
γενικευμένο φαινόμενο, ή αποτελεί
ιδιαιτερότητα του συγκεκριμένου
κλάδου?
There are strong generative relationships in
the sector, but this does not mean that these
could not be found elsewhere, on other
sectors, as well. Perhaps in healthcare, this
phenomenon is more intense.
Generative relationships could be found in
other professional sectors as well.
Probably in the Greek healthcare sector
this is more wide and intense.
Generative relationships are the basis of
protection and solidarity among agents,
but this is a broader phenomenon. In
healthcare there are such specialised
relationships.
There are generative relationships among
groups.
Wherever there is no control, there are
more closed relationships even if these are
generative due to common interests and
status.
Generative relationships is a broader
phenomenon which could be found in
other sectors and not only on healthcare.
The phenomenon of generative
relationships is a general characteristic and
refers to all sectors.
There are relations among groups which
are special and this is due to the sector's
characteristics. In general there are
everywhere generative relationships but in
healthcare are more specialised.
Generative relationships does exist in any
sector. This is rather a general attribute in
communities.
characteristic but in healthcare this may
be more intense.
Generative relationships are a discrete
Generative relationships is a rather
general characteristic in various sectors
but probably demonstrates some extra
specialties in healthcare.
Such generative relationships are specialty
of healthcare sector.
15
Do generative relationships create
contexts in the system? Who is the
main source of such relationships?
Μπορούν αυτές οι σχέσεις ιδιότυπης
αλληλεγγύης να επιβάλλουν κανόνες στο
σύστημα?
Yes, unfortunately this is possible to be done
in the sector.
Generative relationships may impose
contexts but in circumstancial and not in
holistic approach.
Generative relationships could imply
informally new contexts in the system.
Generative relationships cannot create
rules or imply contexts. Contexts are
defined by the Administration of hospitals.
Nevertheless, groups can work for the
alteration of such contexts.
Usually the system does not allow closed
and distorted relations among agents.
and could impose rules in the system.
In healthcare, generative relationships
create contexts. From time to time these
create new informal rules which in long
range harm the sector. For example the
reward and promotion of specific persons
do not always take place with wide
accepted criteria, rather than with
personal.
Generative relationships can impose rules,
either with direct or indirect ways.
Such relationships, in extent, could define
prototypes and create contexts.
but they lack of good organising and
educated members.
Such relationships may impose contexts in
the system.
Such relationships are embedding new
contexts.
Generative relationships do create
16
Do generative relationships have
responsibility for fighting or enabling
changes in structures towards self‐
organisation?
Μπορούν αυτές οι σχέσεις να καθορίσουν
νέες δομές και οργάνωση?
Generative relationships define new
structures and organisation of the system.
(people defines systems and not vice versa). Yes, from time to time this is possible.
Generative relationships could enable
changes in structures and organisation.
Generative relationships cannot create
new structures by themselves.
Such relations include people that stand
outside healthcare sector. Therefore, it is
difficult generative relationships to enable
changes within the sector.
In addition, generative relationships can
define new structures, or even enable a
series of changes towards self‐
organisation.
Such relationships could enable changes
which in addition could direct to right
direction. The new organisation of the
system should quarantee daily evaluation,
objectivity in criteria and agreed
framework from all.
Generative relationships enable changes
but there must be also governmental
willingness to support this decision.
In addition, such relationships could define
new structures and organisation.
Such relationships play a significant role
but they are not the only one in enabling
They may define new structures and
enable changes.
Such relationships possibly enabling and
not fighting changes in structures.
Such relationships may define new
structures.
17
Which is the relation between
generative relationships and patterns
of behaviour? Can this relationship be
the cause of emergence?
Προφανώς αναφερόμαστε στις κλειστές
σχέσεις μεταξύ ομάδων συνήθως του
ίδιου επαγγέλματος ή ιδιότητας. Τελικά
αυτό μπορεί να δημιουργήσει εμπόδια, σε
ένα πολύπλοκο σύστημα, όπως είναι η
υγεία μιας χώρας?
Yes, this creates obstacles. Closed
relationships direct to narrow perspectives,
ideas and in restrained changes and
additions, which in continuous complicate
any reforms.
The relation among generative
relationships and patterns of behaviour is
close, therefore this specialty may create
obstacles for any further developments,
this is very possible.
Closed relationships always create
problems, on every aspect and in every
sector.
Closed relations is the link between
generative relationships and patterns of
behaviour. Such relations create obstacles
in healthcare and may be the cause of
emergence.
Closed relations operate negatively and
create obstacles in the system.
Closed relations create obstacels and
quarrels among groups. This does not help
neither the secto nor the players
themselves.
Closed relations and closed groups are
obstacles in the system's progress.
Relationships are linked to behaviour.
Closed relations affect behaviour.
Nevertheless, healthcare should be placed
above personal or professional relations.
The system must ensure that health is the
ultimate service for all with equal access
and treatment. All agents should be
rewarded and be paid under a strict logical
scheme.
Relationships and patterns of behaviour
may raise obstacles but this again depends
on mechanisms of control. Rules and
control are the opposite of closed
relations.
The closed relationship among generative
relationships and behavioural patterns
may be an obstacle or a cause for
emergence.
This relationship could raise obstacles.
Every kind of relationship needs strong
base. This relationship is responsbile for
the local mentality that cultivated all these
years.
They cannot though raise obstacles, but be
the cause of emergence.
Nevertheless, the relation between
behaviour can create obstacles instead of
emergence.
Closed relations such as the link between
behaviour raise obstacles.
18
What is collective reflexivity? What is
the relation with complexity?
Τι θα χαρακτηρίζατε ως συλλογική
αντίδραση? Υπάρχει σύνδεση μεταξύ
αντίδρασης και πολυπλοκότητας?
Collective reflexivity is the practice of
coordinated attempt for changes
Collective reflexivity is anything that
demonstrates a practice of group reaction
such as: protest, strike, absence, retention,
mass pension. There is collective reflexivity
and is result of reaction.
Reflexivity is synonymous to reaction (e.g.
strike). Any reaction has direct link with
complexity in healthcare.
Collective reflexivity is collective
movement as reaction.
Collective reflexivity is a group reaction
but this does not exist anymore under the
new system, since healthcare
professionals will be obliged sooner or
later to work independently and sign
individual contracts.
Collective reflexivity is the unique reaction
of a group for its benefit. It is not clear if
reaction is linked to complexity.
There is connection among reflexivity and
complexity. Complexity actually suspends
collective reflexivity. In a complex system
it is difficult for a group to react
effectively.
Collective reflexivity incorporates
elements of self‐imposement towards new
rules of work and behaviour.
Collective reflexivity is expressed through
any practice of opposition. This usually
comes as a result of complexity that
implies reactions.
Collective reflexivity is the action of doing
smth in changing, canceling, rejecting
tactics that are considered wrong. This is a
result of the relation between reaction
and complexity.
Collective reflexivity is the unique,
homogenised reaction of a group. There is collective reflexivity. No comment
19
Who is responsible for reflexivity? The
system, the agents?
Ποιοί μπορεί να καλλιεργούν την
συλλογική αντίδραση? Μπορεί να είναι
ομάδες? Μπορεί να είναι το ίδιο το
σύστημα? Μήπως συνδυασμός ή κάτι
άλλο?
Collective reflexivity can be cultivated by
groups.
Responsible for reflexivity are the
politicians and political groups plus trade
unions of the sector.
Political parties and trade unions are
responsible for collective reflexivity and
reactions.
Trade unions and professional unions are
responsible for collective reflexivity in the
sector.
Not only the agents but also the system is
Reflexivity is directed from political parties
and unions. All of them are part of the
system in any case. So, the system has its
own andidote which is collective
reflexivity.
Both the system, the groups and the
employees themselves are responsible for
reflexivity.
Trade unions are responsible for
reflexivity.
Both the system and the agents may be
The combination of agents and the system
is responsible for reflexivity.
The system itself is responsible for
reflexivity. No comment
20
How reflexivity works in healthcare
sector?
Πως λειτούργησε και πως λειτουργεί η
αντίδραση και τα αντανακλαστικά των
ομάδων στον τομέα υγείας όλα τα
προηγούμενα χρόνια, μέχρι και σήμερα?
Unfortunately, there is inertness during last
years in the sector, in terms of reflexivity.
Groups do not present alertness in the
coming changes.
Reflexivity did not operate in an effective
way so far. It used to operate with no
organisation, no programming, and with
no targets. I do not know.
Reflexivity works negatively in the sector
and harms the whole system. In general
terms the system does not help qualified
and valuable employees.
No clear to me, if reflexivity works
positively or negatively.
After so many years the result is that there
is no consensus among groups in
healthcare.
There is no solidarity, or consensus among
the agents during the years. This, in
consequence. stops healthcare system
from progress and keeps it stacked in the
past.
Reflexivity did not work effectively so far.
It worked though in occassions when basic
rights were considered to be broken. The
main reason was that there was no
consensus and group mindset in the
sector. Each group had its own beliefs and
the reaction was rather periodic without
strength and duration.
Ineffectively, without concrete and
definite results but rather with inertia.
Reflexivity works under the supervision of
political parties all these years.
So far there was no reflexivity in
healthcare rather than predefined data
and rules which were imposed and were
followed through time. There is no actual reflexivity in healthcare.
Reflexivity is based on interdependencies
and the combination of groups' powers. No comment
AttractorPatternsGenerativeRelationshipsandPatternsofBehaviourCollectiveReflexivity

16th interview questionnaire 17th interview questionnaire 18th interview questionnaire 19th interview questionnaire 20th interview questionnaire 21st interview questionnaire 22nd interview questionnaire 23rd interview questionnaire 24th interview questionnaire 25th interview questionnaire 26th interview questionnaire 27th interview questionnaire 28th interview questionnaire 29th interview questionnaire 30th interview questionnaire 31st interview questionnaire 32nd interview questionnaire
Hospitals Administration, Doctors, Nursing
staff, Paramedical staff, Administrative
staff, Pharmaceuticals staff.
Doctors, nursing staff, technical staff,
administration. Doctors, nursing staff, pharmacists
Doctors, nursing staff, physiotherapists,
pharmaceutical companies,
pharmaceutical central warehouses,
pharmacists.
Doctors, nursing staff, pharmaceutical
companies, administrative staff, other
supportive staff (cleaning, cooking,
security etc), social services that
participate in the system.
Doctors, nursing staff, administrative staff,
supportive staff (technicians, cleaning etc). Doctors, nursing staff, paramedical staff.
pharmaceutical companies, supportive
staff, physiotherapists, other technical
staff.
pharmaceutical distributors, hospitals,
ministry of health, pharmaceutical
companies, associations, unions,
government, legislators.
Doctors
(private/hospital/clinical/insurance/Univer
sity), Nursing staff, Paramedical staff,
Pharmacists, Pharmaceutical companies,
Pharmaceutical and Medical distributors
and wholesalers.
physiotherapists, speechtherapists,
ergotherapists, biologists, biochemists,
technology labs professionals, chemists,
pharmaceutical companies,
pharmaceutical warehouses, technical
assistants, government, administrative
staff of hospitals, insurance organisations,
insurance companies, state public services,
the national organisation of medicines.
Healthcare system is divided into public
and private sectors in the country. Players
are: doctors, nursing staff, pharmacists,
dentists, paramedical staff, other
supportive professions such as drivers of
ambulances, assistants etc.
Doctors, nursing staff, administrative staff,
paramedical staff, psychologists,
economists, lawyers, politicians.
Doctors, nursing staff, politicians, technical
staff, supporting staff.
companies, administrative staff,
pharmacists.
Doctors, paramedical staff, pharmaceutical
companies, administrative staff.
pharmacists, pharmaceutical companies,
administrative staff, political staff.
1. Hospitals Administration, 2. Doctors, 3.
Pharmaceutical companies 1. Doctors, 2. Nursing staff 1. Doctors, 2. Pharmacists, 3. Nursing staff
There are two strong groups which
demonstrate their own hierarchy; 1st
group: (a) Doctors, (b) Nursing staff, ©
Physiotherapists; 2nd group: (a)
Pharmaceutical companies, (b)
Pharmaceutical central warehouses, ©
Pharmacists.
1. Pharmaceutical companies, 2. Doctors,
3. Nursing staff that belong to unions.
The most powerful group is the one that
has the capitalised strength to impose
changes in the system. This is troika. The
privatisation of healthcare in the country is
supported towards specific interests.
Therefore outside interferes due to
political decisions.
In a healthcare system which is doctor‐
centered, naturally the main role is played
by doctors. Second, the nursing staff is
significant, since this is a new dynamic
group which plays a significant role as well
and tries for advancement.
1. Doctors, 2. Pharmaceutical companies.
These two powers play the major role in
the sector.
1. Government, 2. Legislators, 3. Ministry
of Health, 4. Unions, 5. Doctors‐
Pharmacists‐Pharmaceutical distributors‐
Hospitals, 6. Pharmaceutical companies.
1. Pharmacists (due to their strong union),
2. Doctors, 3. Nursing staff, 4. Paramedical
staff.
Group A: Doctors, State, Pharmaceutical
companies and warehouses, Group B:
Patients, Group C: Public Insurance
Organisations, Group D: Supply
companies, Group E: Administration,
Group F: Lab professionals, Group G:
Nursing and paramedical staff.
All groups have power and play significant
role but if we would like to prioritise them
we have to consider the level of
healthcare provision (First‐Second‐Third).
In first healthcare level, doctors, nursing
staff and paramedical staff are important.
In the other two levels of provision,
doctors, nursing staff, dentists,
paramedicals, assistants. In all these
provisions, it is necessary the existence of
pharmaceutical companies. Most powerful
groups are doctors and nursing staff.
These two groups with the cooperation of
pharmaceutical companies play significant
role in the system.
1. Politicians, 2. Doctors, 3. Lawyers, 4.
Economists, 5. others. 1. Politicians
Most powerful groups are: 1. Doctors, 2.
Nursing staff (Heads). In current situation,
primary role are playing pharmacists. All categories have power in the sector. 1. Administrative staff
Information is formed by outside centers
such as Mass Media.
Doctors have inside information and they
are responsible for forming the
information as well. There are no
monopolistic situations in terms of
information administration, and
technology can help in the development
and restrain information asymmetry.
Information is administered outside the
sector. Journalists and centers of press are
responsible for the infusion of relevant
information. Use of technology can help
theoretically but not in practice.
Information is actually administered from
pharmaceutical companies; Monopolistic
phenomena are referred to medicines and
their markets. These contribute in the
rolling of information in the system. Use of
technology can definitely help in
restraining information asymmetry.
Inside information exists among
pharmaceutical companies, doctors and
University medical staff. Use of technology
could help in terms of clarity in the system
and the relations among groups.
Actually none has full access to
information. For example doctors have
restrained access. Nevertheless, it is
absolutely necessary to ensure
accessibility to information, especially for
the modern doctors.
Pharmaceutical companies play the
significant role in information
administration in the system. These
companies decide who will have access in
information and the range of this access as
well. Use of technology is theo door for
the modernisation and democratisation of
information for all.
Priviledged accesibility in information is
focused on doctors who are the main
receivers of various information mostly
from pharmaceutical companies through
pharmaceutical representatives. Free
access in technology and information will
help the administration information.
Inside information has every group in
terms of its own priorities. Technology can
improve information administration as
well as the control over information. It is
true that during last years many groups
have access in information. Steps taken so
far are small though but to the right
direction.
Information asymmetry exists everywhere,
since any group can gain access depending
on the resources it acquires. Information
administration is a broader issue of fair
treatment and credibility.
There is information asymmetry since
some groups form and administer the
information and these are groups A, D and
F because they have the ability to
cooperate with external scientific
communities and have the knowledge.
Nevertheless, the adoption of technology
gradually helps also patients and others.
Monopolistic phenomena in regards to
information exist mostly from
pharmaceutical companies. Regarding the
supply of goods, the monopolistic situation
is less. Regarding the information created
by the government still the access is
restricted especially in terms of any
changes in healthcare system.
Inside information has to do with two
issues. First with the information that is
produced by private companies and non‐
governmental organisation which create
information and promote it for various
reasons, e.g. advertisments, mostly for
their personal interests. Such groups have
direct access to the society. Regarding
medical issues, pharmaceutical companies
still have the power to form information.
They create monopolistic situations and
this affects the economy of the country.
Pharmacists used to be a powerful
monopolistic group as well, at least until
some time ago. Regarding doctors, any
inside information has to do mostly with
their scientific tasks, since their job is too
specialised. Any monopolistic behaviour is
related to the nature of their job and
expertise which among others, is very
significant for the society.
All groups have access and form
information. Possibly doctors might have
some privileged access. There are no
monopolistic phenomena in the sector.
Technology can help in the administration
of information.
Politicians have more accessibility to
information. Technology could improve
information administration.
Information is administered by nursing
staff and the pharmacists. Pharmacists
have priviledged access to technology.
Technology, as a mean could help in better
information administration.
There are monopolistic phenomena in the
sector, in regards to information
administration, but technology will help
and it is necessary.
Doctors have better access to information
since they form it as well. Pharmaceutical
companies on the other side create
monopolistic phenomena in terms of
information administration. More use of
technology will help definitely the sector.
Relations among groups exist and are very
significant.
important and there are strong
interdependencies which affect the
progress of the system as a whole.
Of course there are relations among
agents in the sector. Although these are
not considered important, there exist and
unfortunately affect the sector. As a result
such relations might play either a positive
or negative role.
There are strong pairs of relations among
agents such as: doctors‐pharmaceutical
companies, pharmacists‐pharmaceutical
warehouses and distributors,
pharmaceutical companies‐pharmaceutical
distributors. Such relations play significant
role in the sector since these define the
framework upon the system works on.
These contribute both negatively and
positively since these define any
developments.
Relations among agents exist and are very
important.
The whole system is built on relations and
interdependencies. This is how it is
structured. In any case, this implies the
definition of a system. Any progress is
result of how such relations operate and
affect participants and groups.
Doctors have direct relationship with
pharmaceutical companies, something
that is acceptable to an extent, but beyond
this, in general, it is dangerous for the fair
treatment of patients.
The relations among agents in healthcare,
are relations of interdependence and
interaction. Such relationships could boost
knowledge on the one side, while on the
other side could affect negatively.
important and to an extent that affects the
supply chain of the system.
Certainly there are relations among agents
especially between doctors and
pharmaceutical companies. This
relationship has both negative (over‐
prescriptions of medicines) and possitive
(pharmaceutical companies fund research
and organise congresses) effects. The
wrong manipulation of such relationship
may direct to commercialisation of
healthcare.
Of course, there are relation and
interedependencies among groups in the
sector. Actually there is a chain of relations
among groups which is very significant for
the survival of the sector. Such
interelations define policies and how these
are applied. On the other side, these
different relations are responsible for the
different implementations of the same
policies in the same sector.
Of course there are interelations among
groups. A classic relation is among doctor‐
nurse in the level of daily practice within
the clinic. Interelations are also among
other groups in terms of cooperation for
the benefit of the sector, in areas that is
not so obvious. There are though some
interelations that should be stopped such
as between health professionals and
pharmaceutical companies for personal
benefits.
There are relations among groups which
are important because they affect the
operation of healthcare provision. In
addition they affect both positively and
negatively the progress in the sector.
are important and may contribute in any
evolvements in the sector both positively
and negatively.
There are strong relations among groups.
However, now that prices are controlled,
relations change especially between
doctors and pharmaceutical companies.
are very important and contribute
positively in the progress of the sector.
There relations among agents which are
important.
Relations patterns are defined both by the
system and some groups. Actually the
structure of the system helps preservation
of current patterns.
system.
Relations patterns are defined by a
combination of groups and the
competition.
The answer is the system. The system has
been structured in such a way that nobody
can proceed alone. Everybody needs
everybody.
government and its agencies which create
the framework.
The system defines relations patterns in
general terms. Of course this, from time to
time, is affected by personal interests of
groups.
There are strong castes within medical
group which affect the system and
reproduce current mentality for the
benefit of these groups.
The healthcare system itself, and the way
this is structured defines the internal
relationships.
The governments so far and their
mechanisms are responsible for the
relations patterns.
Mainly the system defines relations
patterns and this is due to the existed
ankylosis.
The system defines the interelations. The
system and its organisation, enables
groups and allows such relations.
The system defines the relations patterns
in a certain extent. Since the staff is
obliged to cooperate and interact, it is
inevitable not to exist relationships. The
nature of such relationships and whether
these are positive or harm the system
depend on the personalities of the
participants.
The system defines the relations patterns.
This is due to how this is organised and the
existed structures. Current system is
doctor‐centered focusing in classical ways
of managing and hierarchy.
Relations patterns are defined by personal
initiatives.
All the above, are responsible for defining
relations patterns.
Both the system and the building blocks of
groups are responsible for defining
relations patterns. The system defines relations patterns.
this creates paradoxes and distortions.
Interdependencies may raise paradoxes
but from time to time, not always.
Yes, relations create paradoxes and
distortions and actually this happens very
often.
There is equivalence among groups and
interdependencies demonstrate a kind of
equivalence among the groups as well.
Such organisation of powers could create
paradoxes.
Interdependencies are result of relations
which exist, such as between doctors‐
pharmaceutical companies. A paradox
stemmed from interdependencies is that
many valuable staff decide to leave
healthsector and go abroad. Certainly such relations create paradoxes.
Certainly relations create
interdependencies which generate
paradoxes. Such relations affect patients
negatively.
There are specific relations that create
interdependencies in the system. Such
relationship is between doctors and
pharmaceutical representatives which
damage the sector and bring paradoxes.
These relations exist and have definitive
stress regarding any evolvements in the
sector. They do create paradoxes and
problems in healthcare.
Relations create interdependencies since
the human factor demonstrates emotional
vulnerabilities or even money
dependencies.
Relations do create interdependencies and
these raise paradoxes mostly stem from
the groups that are in the beginning of the
chain of relations. These are:
administration‐government,
administration‐doctors, doctors‐
pharmaceutical companies.
Paradoxes and distortions do exist only in
the occasion of misusing these relations
for personal benefits.
Interdependencies could create paradoxes
only in the cases of individuality,
competition, introversion, intolerance and
autarchy. Relations do create interdependencies.
An interdependence might create
paradoxes in the system.
this enables paradoxes and distortions.
these create distortions.
Current powers cannot help in self‐
organisation and cannot contribute in
revealing new powers.
Interdependencies may help in unleashing
new powers towards a new self‐
organisation of the system, but I do not
know if they can direct to changes.
Such relations might enable changes but
in a small range. Regarding emergence and
self organisation this necessitates the
cooperation of various factors and powers.
Groups and their interdependencies have
the power either to block or boost
emergence and self organisation.
Such relations may destroy the whole
system. Healthy powers cannot succeed if
current system remains.
The system is strongly structured and with
strong interdependencies and relations. As
a result, given the current situation, it is
difficult for the system to reach a new self‐
organisation and new powers to be
revealed.
Personal and independent reaction is
much more important than
interdependencies. Every participant in the
system should consider carefully his/her
participation and action and should fight
for the best. No comment
State and government are the entities who
usually block any progress due to their low
level of intelligence, information and
knowledge they have.
It would be wrong to allow the sector to a
new self‐organisation at least without
control, unrestrained.
Interdependencies create obstacles and
block any new powers. Current system
does not have a fair system of evaluation
and control. For example, doctors choose
specific medicines and promote specific
health tests. Under these circumstances,
any progress is difficult. In addition, the
sector has many groups which have many
interelations, therefore it is difficult to find
its self‐organisation.
It is possible for the interdependencies to
enable new structures and organisations
without creating problems in a hospital for
example. Good relations and
interdependencies could create new units,
clinics and develop the environment for
new cooperations. Such services though
should always be available to all patients
and not only to the rich ones.
Interdependencies may cause changes but
this prerequisites a good administration of
change, knowledge, persistence and
cooperation.
Such interdependencies can cause changes
in the system.
It is difficult for interdependencies to
enable new powers and a new self‐
organisation in the system. I see this
accomplishment as very difficult.
Interdependencies could enable changes,
as long as, there will take place some
radical changes in the structures of the
system.
Such interdependencies could enable
emergence of new powers in the system.
There is heterogeneity and this is rather
wide in the sector.
In healthcare there are different groups
which produce heterogeneity. This
difference among groups is huge.
Heterogeneity stems from different
initiatives and targets that different groups
have. This heterogeneity demonstrates a
big range.
There is heterogeneity and its width is
defined by the initiatives and wills of each
group seperately. Heterogeneity
demonstrates an additional grouping such
as Pharmacists‐pharmaceutical companies‐
distributors.
There is no heterogeneity in healthcare
system.
Definitely, heterogeneity exist in the
sector. This stems from the different aims,
roles, motives and attitudes of the groups
that work in the sector. Responsibilites are
different as well. Some specific employees,
especially doctors, have the primary
responsibilities in the system.
In the sector there are different groups
which do not necessarily have common
ground for cooperation. There is
heterogeneity which is revealed through
evolvement of things. Every group is an
equally active member and a possible
attractor for change, attracting the others
to better prospects. No comment No answer
Diversity‐heterogeneity is a general
phenomenon in all labour fields. Of course,
each group has its own specific aspirations
and this by itself brings differences.
Heterogeneity exists especially in terms of
scientific orientation and education, the
level of knowledge and abilities, the level
of responsibilities. Also heterogeneity
includes any personal ambitions and
individuality.
There are different groups in the sector
but with common targets and common
vision. There is heterogeneity but this does
not make them different for the benefit of
the services provided.
There is heterogeneity but this is not wide.
Since groups have common targets they
interelate and co‐exist in a common route.
Heterogeneity exists due to different
obligations and different targets of the
groups that exist in the system.
There is heterogeneity among groups and
this is based on the difference in
responsibilities and tasks. Doctors care for
patients, companies work for keeping
doctors satisfied, nurses are in the middle
and administration might or might not
interfere in these relations.
There exists heterogeneity but not in a
wide sense. Heterogeneity exists in the system.
Heterogeneity sometimes blocks
cooperation and consensus, therefore this
is a problem for the sector.
Heterogeneity could be observed
everywhere in the sector and this does not
create any problem for the country.
Motives and results are the main
attributes of diversity. Heterogeneity
creates problems for the country in
general. The only way to help positively is
when this contributes in forming a clear
competitive environment.
Heterogeneity could be observed and
found everywhere. If heterogeneity is
administered succesfully it will not create
problems.
There is no heterogeneity in healthcare
system.
Heterogeneity could be observed in any
place, espceially where the clinical work
takes place. In back up operations, such as
lab assistants, administration,
heterogeneity is not so obvious.
Heterogeneity is sourced from people
mostly and not groups. No comment No answer
Heterogeneity could be observed mostly in
hospitals and this is not found only in
Greece but in other countries as well.
Heterogeneity could be seen in all sectors
and this is not negative for the country.
Heterogeneity could be mostly seen in
hospitals. Sometimes heterogeneity is
cultivated by the system and transforms
internal groups since they do not have the
same treatment from the system. For
example, during crisis, there are hospitals
that are obliged to cope with much more
patients although they do not have the
appropriate budgets. This is more intense
in specific areas such as in the hospitals of
Epirus. Therefore, there are not only the
given heterogeneities but also the ones
that are nurtured by the system itself. If
the situation was better heterogeneity and
interdependencies would be creative and
finally would help much more.
Heterogeneity exists and starts from the
education of different groups. This is not a
problem though as long as there is
consensus and groupwork.
Heterogeneity do not create problems as
long as there is effective cooperation
among member groups.
Heterogeneity could be seen in hospitals.
Sometimes it could be a source of problem
especially when there are no controls, e.g.
uknown medicines that are used in the
sector.
Heterogeneity is not a problem for the
country. Heterogeneity could be seen in hospitals.

Heterogeneity may be a source for
development.
development.
development only when this operates
productively and correctly.
Heterogeneity can be a source of
development.
Heterogeneity and difference do not exist
in terms of evolvement.
Heterogeneity is more of a source of
problems and tensions rather than a
source of development. Heterogeneity is
something that I do not recognise.
Heterogeneity should be a source for
development. No comment No answer
development.
Heterogeneity can be a source of
development if personal differentiation
could be homogenised for the common
benefit under an effective administration.
Probabably heterogeneity is the source of
development but it cannot progress alone
without the help of society and vision from
the staff which abort any negative
relationships.
Yes, heterogeneity could be a source of
development but with the help of cultural
changes and change in mentality.
development.
Heterogeneity could not be a source of
development.
development.
development.
Attractors are the top management of
hospitals and the doctors.
Attractors are not persons or groups
rather than the law, ethics and the
framework that exists and everybody
follows.
As attractors we can define doctors and
pharmaceutical companies and these
groups form the relevant patterns as well.
Mainly this starts from pharmaceutical
companies.
Attractor patterns are formed by
attractors who are the leaders of the
groups that participate in the system.
These leaders define the behaviour of the
members.
Attractors in current system are trade
unions and parties who cultivate the
relevant patterns. Rest of participants just
follow and do simply their jobs. Some of
them could be really good examples for
the ones though who are ready to see the
difference.
Current attractors are the political
mouthpieces who operate under their own
interests, such as the Administration of
Clinics in Hospitals, Directors etc., who are
motivated by personal, economic, legal
and job distribution motives.
There are no attractors. There are no
examples and prototypes to follow. This is
something that we have to dig and find.
The Greek healthcare system is doctor‐
centered. Doctors are attractors. The
Government is an attractor as well. These
two define the patterns.
State defines patterns in the system, so
the State is the main attractor who using
the legal framework places guidelines and
restrains.
Regularly attractors should be the Ministry
of Health and the Code of Ethics of the
sector. But nowadays patterns are
affected and followed differently from
different groups and seperately.
Patterns are defined by the groups.
Individuality plays a significant role.
Nevertheless, since healthcare is a
significant element for the society,
patterns are defined also under the
requests of society in extent.
Attractors are mainly the health
professionals of the system. Then, the
government.
Behavioural patterns are defined by the
educational institutes.
dominant groups.
Attractors define patterns and these
usually are the unions of the groups. These
are the professional associations that
represent employees.
The system itself defines behavioural
patterns and each agent separately.
Human resource is responsible for the
definition of the patterns in the system.
Behavioural patterns will not work unless
managers and doctors change their
patterns. Behavioural patterns can certainly change
These patterns work both positively and
negatively. Nevertheless, these impose
contexts and they additionally can help
changing the structures.
Patterns operate both negatively and
positively and these may change contexts
or even create new contexts in the sector.
Current contexts and behavioural patterns
are imposed by the pair: government‐
unions who have destroyed productivity.
Behavioural patterns are always expressed
within the system's limits. Systems do not
self‐organised. Such an attempt is rather
failured. On the contrary all members
should work towards the structure of the
system.
Behavioural patterns and the system can
accept many changes and everyone is
responsible. No comment
Such patterns introduce contexts. The
main issue though is who controls these
contexts and who is responsible for being
applied.
Patterns affect the system and may
change the structures as long as these are
working for the benefit of healthcare.
Patterns of behaviour can change. Already
current restructure have helped in better
administration. Of course this mostly
concerns public services and organisations.
Groups that work on private sector follow
other patterns under different schemes.
History has proved that patterns of
behaviour followed did not help the
system. The change of the system is
expected to alter the behaviours as well.
The turn to privatisation will possibly help
the system by creating competition and
healthy ground for new patterns.
Behavioural patterns can change in a new
system and this is common expectation in
healthcare sector. A new system with a
new management towards quality and
progress. Patterns do not change in a system.
Behavioural patterns have affected either
positively or negatively the sector. These
patterns cannot change since the country
does not have enough resources.
Behavioural patterns have operated
negatively so far for the system. They can
change though.
Behavioural patterns are definitive for the
progress of the system. But it is very
difficult to be changed, there are few
possibilities.
Unfortunately the new system should be
built from zero and the old one should be
destroyed.
A new system could be based both in old
and new powers.
The system should be destroyed and be
rebuilt from the zero.
On the one side the system cannot work
without attractors. A system cannot be
based in its old powers, if this wants to
survive. There are needed dramatic
changes which mostly deal with the
existing culture and mindset. Such a
system cannot withstand a transition in a
new stage. Therefore, i consider that the
system should be destroyed, and be
created from the beginning.
The system needs new attractors, in order
to gain a new perspective. The new system
cannot base itself in old powers and
mostly based on existed mentality and
culture. As a result, the old system should
be destroyed.
The destruction and building on new
foundations is the only solution, as it
seems from rational explanations. Current
system does not allow for restructuring
and repairings.
Nothing is possible to be built from zero.
Everything is a result of progress. Under
this case there must be a progressive
power which will undertake the
responsibility to lead changes.
It would be better for the system to be
structured from zero level without the
commitments and the past previous
practices. No answer
attractors. It would be better to keep a
combination of old and new powers in an
effort to make changes in the system. We
should keep good practices from past.
A system could progress based on
knowledge, abilities and money. The
better use of resources and a better
administration are enough for the changes
to take place.
The system could progress keeping the
good elements from the past. However it
is necessary to apply new competitive
techniques and destroy any monopolistic
phenomena for the benefit of healthcare
provision in the country.
To destroy and build again a system that
incorporates the negative action of
catastrophe. Our system is not so decayed.
It needs a change of culture, renewal and
stimulation.
rebuilt from the beginning.
rebuilt on new foundations.
It would be better for the system to be
rebuilt from the beginning on new
foundations.
The system could be better to be built
from the beginning.
phenomenon.
Generative relationships exist in other
sectors as well but in healthcare this is
more intense.
I consider that there is no other
relationships. There are no generative
relationships.
The existance of generative relationships is
a characteristic of all sectors and
professions in the country.
Generative relationships is a social
phenomenon result from the instict of self‐
presevation of a group which lives in a
broader complex system.
Generative relationships is rather a
general phenomenon but each sector such
as healthcare demonstrates its own
characteristics during the adoption of this
phenomenon.
It is impossible for a sector such as
healthcare  not to have generative
relationships and solidarity.
There are special relationships of mutual
help and intercoverage among healthcare
groups.   No answer
general phenomenon.
There are relationships of protection and
help among groups which enable mistakes
and restrain prosperity for the people. In
the public sector, generative relationships
are stronger and decisions are taken on
group basis where any mistakes are
undertaken by the responsibility of the
whole group.
Generative relationshps do exist, and this
is a general phenomenon which could be
found in many other sectors. These
relationships are closer and more
protective and sometimes they could not
be identified directly.
Solidarity and help among groups is a
general phenomenon while in healthcare
this is more intensive due to the nature of
the sector.
Generative relationships are a general
phenomenon.
Generative relationships are rather a
general phenomenon.
Generative relationships exist elsewhere
as well, but in healthcare sector could be
found more often.
Generative relationships is a specialty of
healthcare sector.
contexts in the system, if the system
wishes to do that.
contexts in the system. This is possible.
Since such relations do not exist they
cannot create contexts or affect the
system.
Generative relationships could be used as
a leverage for changing contexts but the
issue is for the benefit of whom, this
usually happens.
Generative relationships cannot impose
new contexts especially when mentalities
are offended and personal belongings are
jeopardised.
and they do it already.
Generative relationships should be more
active and support a humanistic
environment in the sector.
Generative relationships may create
contexts. For example they impose silence
and camouflage in problematic situations. No answer
the system which operate either positively
(cultivation of common interests) or
negatively (oppositions).
Such relationship may create contexts in
the system. It is good though to take into
consideration patients' status.
Depending on their power, such
relationships can affect and introduce new
the system and this does happen in daily
routine.
in the system.
No, the specific relationships cannot
impose conrtexts. These relationshps could impose contexts.
This kind of relationships could impose
contexts.
structures and new organisation, if the
system wishes to.
Yes, such relationships can define new
structures.
There are some kind of relationships in the
sector which enable changes in structures
and organisation.
Generative relationships have the
responsibility for enabling or fighting
changes. But this depends on the groups
that will try to exploit this priviledge.
Generative relationships are not
responsible for any changes. The system as
a whole is much stronger and administers
information.
Generative relationships include a set of
informal principles. These principles are
rather responsible for structures,
behaviours and organisation in the system.
On the contrary, the formal hierarchy is
not so significant and decisive in future
actions.
Certainly, generative relationships are
carriers of change in a fluid and redefined
environment.
Such relationships should be changed first,
and then create new structures. No answer
Nevertheless, generative relationships do
not have such power to define new
structures and new organisation of the
system.
Not necessarily. The healthcare system
demonstrates weaknesses but this is not
due to weak relations of protection and
help. Generative relationships may direct
to new structures and organisation, but
the issue is who will make the decisions.
Usually, generative relationships do not
affect positively the sector. It for sure that
such relationships should be separated
from the sector and the general
provisional scheme.
There have to be made new mixes and
interactions, in order the relations to
change structures and organisation.
Also, generative relationships could enable
It might be possible to enable changes in
structures though.
They could enable new structures and
organisation.
Generative relationships enable new
The relation between behavioural patterns
and generative relationships can and
definitely create obstacles.
Closed relations create obstacles and raise
blocks in a system.
There are some kind of closed relations
which may create obstacles.
Relation between generative relationships
and patterns of behaviour exist. The
manipulation of them can create problems
or the opposite, help progress of the
sector.
Any special relations cannot affect or block
any system.
Closed relationships as a result of
generative relationships and behaviours is
what is known as "status quo" in the
sector. These are responsible for the
malfunctioning of the system, but it seems
that they have wide acceptance.
The relation between generative
relationships and patterns of behaviour
can find obstacles but not create. It is
required though such relationships to be
based on equality and fairness. No comment No answer
In a complex system, closed and special
relations may certainly raise problems in
the system. Not to forget that aspirations
of participants are not always the same.
Generative relationships is possible to
create problems in the system of a
country, especially when dominant groups
take decisions. Dominancy creates
distortions, since every part of the system
is useful and not only dominant groups.
These close relations are not always bad or
negative for the system. Sometimes these
are necessary. This does not mean that
they cannot create problems in patients.
However, such closed relations are not so
important because they represent a small
percentage.
Closed relations means cliques. Such
relations are obviously obstacles in any
progress and improvement in the sector.
Closed relations create obstacles in the
system and block emergence. No comment
Closed relations could not create obstacles
in the system.
Such closed relations may be an obstacle
for the sector.
Not understand the question.
Collective reflexivity is like the action of
strike. I consider that there is link between
reaction and complexity.
Collective reflexivity is a way of group
reaction such as strikes, protests and in
general group reactions of any nature.
There is relation between reflexivity and
complexity.
Collective reflexivity are the mass
movements. There is a link between
reaction and complexity.
Collective reflexivity does not actually
exist, because it proved difficult for people
and groups to communicate and
cooperate in terms of challenging new
things.
Collective reflexivity is the group reaction
and the cooperation towards common
targets. Though, there are not common
targets and desires in the sector. Reaction
has not to do with complexity itself rather
with current prototypes of self interests
that are cultivated by current system.
Collective reflexivity is the collective
attitude towards a phenomenon. It is
probable such attitude to forward
progress. This is a healthy behaviour for
the system.
Collective reflexivity is the group reaction
against something specific. No answer
Collective reflexivity is considered the
reaction of a group of individuals that
oppose to a certain attack in their
interests. Usually this covers their
common interests and not necessarily
their personal interests.
Collective reflexivity is the action of people
towards common goals. There is
connection between reflexivity and
complexity since groups that participate in
the common action do not necessarily
have the same motives. Therefore, it is not
always given that groups will reach their
goals.
Collective reflexivity is the sum of the
efforts of a group wih common
expectations, targets, desires. Complexity
sometimes is possible to fire reflexivity
and the opposite. As a result complexity
and reflexivity have a bothway
relationship.
Collective means altogether. Reflexivity
has a negative meaning and complexity a
positive one. Collective reflexivity in the
framework of complexity is still something
we are looking for. Collective reflexivity is the mass strikes.
Collective reflexivity means group reaction
and cooperation among groups. This is not
possible though, since there is strong
diversity and each group has its own
targets and motives.
There is connection between reflexivity
and complexity.
Collective reflexivity is any kind of group
reaction. This has a link with complexity.
The system does not create or support
reflexivity. On the contrary the system
tries to divide collective reactions.
Trade unions and parties are mainly
responsible for reflexivity. Moreover,
government, the system itself and groups
are also responsible for cultivating
reflexivity.
A combination of all is responsible for
reflexivity (the system and the agents).
Trade unions are responsible in the
country for collective reflexivity. Especially
there are specific groups in the country
that lead this reflexivity. Finally reflexivity
is a combination of the systems and
individual groups.
Reflexivity is something which is
technically produced by the system in
order to be canceled by it in the end.
Reflexivity comes when groups realise that
they have more commons than
differences. Poverty, undervalue and other
difficulties probably will direct groups in
collective reflexivity. Such situations drive
majority towards the desire for reaction.
The system and its groups are responsible
for reflexivity,
The system and the agents are responsible
for the cultivation of reflexivity. No answer
Usually, unions are responsible for
collective reflexivity as well as any other
associations.
The system is responsible for reflexivity
and the groups are responsible for the
cultivation of reactions.
Collective reflexivity is created by the
system. Nevertheless it is possible to be
created by closed groups which create
general problems and operate against the
system with war mentality.
Everyone is responsible for reflexivity. The
creation of an environment of collectivity
is necessary to create a dynamic
healthcare system.
Responsible for reflexivity are the groups'
representatives.
Both system and agents are responsible
for reflexivity.
Both the system and agents are
Both the system and the agents are
Which reaction? Which reflections?
Reflexivity have operated negative for the
system.
Reflexivity works in both ways. Positively
and negatively.
Collective reflexivity has operated
successfully so far, but now, any things
that have  been acquired by the groups is
about to be lost.
Reflexivity operates like having
experienced a brain stroke and now does
not understand anything at all.
Reflexivity does not work. Every time that
any group tries to react there are always
oppositions in the system, which try to
terrify, and blackmail. The only way for
reflexivity to work effectively is when
there is a decision for final abruption.
Reflexivity was based in the strategy of
splitting the powers in order to weaken
them. It is time for a different "modus
vivendi".
Reflections of groups are delayed in the
sector. No answer
Reflexivity works ineffectively and
unevenly so far.
Reflexivity works positively in terms of
pushing for changes in the system which
finally accept to do. There were always
reactions from groups for various issues
(economical, human resource issues etc),
especially nowadays where the system
works with many difficulties. Nevertheless,
reactions have impacts to weaker groups,
such as the patients. In addition, reactions
are taken into consideration with delays
which harms the system.
Reflexivity works a‐posteriori in the sector,
when problems have alread cretated and
impacts are diffused. On the other side we
should not forget that due to reflexivity
both staff and patients acquired some
rights.
Unfortunately, the rule of "action‐
reaction" works very negatively in
healhcare, just as in other sectors as well.
This operates for the benefit of personal
motives and interests. Nevertheless,
healthcare should be a multi‐side place, an
open place of communication and
professionalism.
Reflexivity worked unevenly so far in the
sector.
Reflexivity works both positively and
negatively. The truth is that in this period
the sector is going to experience very bad
situations due to crisis.
Reflexivity did not work as expected, since
the system was not organised well.
There is no consensus and group reaction
all these years in the sector.

33rd interview questionnaire 34th interview questionnaire 35th interview questionnaire 36th interview questionnaire 37th interview questionnaire
companies, administrative staff.
Nursing staff, Doctors, Technical medical
lab assistants, pharmacists, administrative
staff, technicians, biomedical staff,
physiotherapists, ergotherapists,
psychologists, social workers. Doctors, nursing staff, paramedical staff.
Government and Ministry of Health,
Administration of Hospitals, Unions,
professional associations, pharmaceutical
companies, doctors, companies that are
involved in the sector.
Ministry of Health (central government),
pharmaceutical companies, doctors and
nursing staff.
1. Doctors, 2. Nursing staff.
1. Doctors, 2. Administrative staff, 3.
Nursing staff, 4. Technical staff, 5.
Paramedical staff. The one group supports the other.
The most powerful group is Government.
Government does not want any changes.
The most powerful group is Government.
All other groups have been eliminated.
Doctors and administrative staff are
responsible for the information
generation. Use of technology may
improve information administration.
Doctors and nursing staff are the groups
that create information. There is no
privileged access for any group. Use of
technology could help in the improvement
of information administration.
There is no actually a unique group that
has more access in information.
Information administration is a matter of
personal initiative. As a result groups have
restrained access. The use of technology
will definitely help.
Government continues to administer
information which still creates problems
although we live in the era of free
information. Issues that should have been
solved remain unsolved.
Information administration is done by
mass communication media. It is not clear
whether there are monopolistic
phenomena.
Relations among agents are important and
contribute positively in the progress of
the sector.
There are relations which are important
and could be used for the benefit of the
healthcare sector. Especially for the
benefit of patients.
Interelations are inevitable in an
environment where strong relations exist.
These are positive and necessary for the
system.
There are relations among groups that
create dependencies in a degree of high
protection.
Healthcare is affected by all its members.
Relations are very important. When a
sector malfunctions affects others as well
and decrease the level of healthcare
provision.
The system defines relations patterns. The
Directors of Clinics are responsible for the
relations.
The interelations and relations patterns
are defined by the system and the groups. The groups define relations patterns.
The system defines relations patterns and
founds itself at the beginning of chain. The system defines relations patterns.
Relations and interdependencies create
paradoxes in the system.
When relations are not equivalent then
there are distortions.
Distortions are the result of personal
actions and not the result of
interdependencies.
There are no paradoxes in the system
since each group knows that depends on
the others.
There are paradoxes and distortions for
which the system has therapies.
Such relations could help the system. They
could help in unleashing new powers
subject to successful selection of new
staff. This needs patience and persistence.
Relations could enable changes in the
system and if these relations are healthy
could change the whole system.
Interdependencies can cause changes
through a series of interactions among
groups. Such relations could enable changes.
New healthy powers will direct to new self‐
organisation.
There is heterogeneity which stems from
different purposes and targets. These
differences could break balances.
There is heterogeneity among groups in
the sector and this is due to the specialties
of each profession.
Heterogeneity exists due to different
groups. This is wide and necessary for the
sector.
There is heterogeneity but the target is the
same. More profit from the sector.
Heterogeneity depends on different
groups and these groups converge. The
more diversity exists among groups the
more diminishing services are offered.
Heterogeneity is a problem, especially in
the workplaces. This is more emphatic
when incapable people work in the sector
affecting badly the quality of employment.
Heterogeneity exists between two main
groups. From the one side doctors and
nursing staffadn from the other side
administrative, paramedical and technical
staff.
Heterogeneity stems from the multiple
roles of structures in healthcare. The
bottom line is the effective therapy and
treatment of patients. As a result
heterogeneity is not a problem since this
does not affect the quality of offered
services.
The heterogeneity is not accepted in the
sector because if this was accepted we
wouldn't enter in crisis.
Heterogeneity could be identified in
central government, universities and
hospitals. Nevertheless this is not a
problem for the country.

It is not necessary that heterogeneity is a
If heterogeneity is creative then could be a
Yes for sure, diversity is always a leverage
for thinking and acting towards results.
Heterogeneity creates progress and this is
the solution.
development if all groups decide to evolve.
The ones who participate in the system
are responsible for attractor patterns.
Patterns and behaviours are defined by
the society and its citizens in every
different phase.
Attractor patterns is the result of
evolution. There is no any specific
dominant power that defines patterns
rather than interaction among members.
The powers that define attractor patterns
are the ones who are responsible for the
current situation in healthcare sector and
in Greece.
politicians, the educators and the church.
Patterns work both negatively and
positively.
Patterns could impose contexts and have
the power to change systems and their
organisation. I have already replied based on the above.
Yes, the attractor patterns can impose
contexts but there were not the
corresponded evolution all these years.
Behavioural patterns are not independent
from the healthcare operators.
Behavioural patterns follow the rules of
new self‐organisation.
The system should be rebuilt in new
foundations.
A new system needs also the old healthy
parts of the previous system. It can
improve the old parts through time.
Nothing can be rebuilt on totally new
foundations. Everything is under a
developmental relation between
yesterday and today. This is a detailed
relationship to the end.
It would be better to build again the
system on new foundations.
The system should depend on both old
and new powers. In this way the system
will handle the transition normally and not
through catastrophy.
general phenomenon.
Generative relationships os rather an
isolated phenomenon and not a general
one.
Generative relationships are the basis for
interaction, solidarity, humanity and help
among members. We have to consider
that the final receiver in the system is the
human being.
Generative relationships harm the system
because these are maintained from the
groups that have damaged it.
Generative relationships are the
the system.
Generative relationships could impose
rules in the system.
Generative relationships impose an
informal rule and a code of ethics among
their members. Since this is rather a flabby
approach we could talk also for formal
rules. No they cannot. Yes they can.
Generative relationships enable changes in
structures towards self‐organisation.
But they cannot define new structures and
organisation.
structures but it takes time. No they cannot. It should be.
The relation between generative
relationships and patterns of behaviour
creates problems in the sector and in the
country. It is questionable who finally
manages the system. Yes this relation can cause problems.
The problem is where the new system will
be based on. The emerging powers will be
the result of the mix of different powers.
Closed relations are the problem. It is time
for clarity.
Closed relations remain a problem and an
obstacle.
Collective reflexivity is the concurrent
reaction of a group.
Collective reflexivity is every action of
workers against decisions that insult their
interests. There is a direct relation
between collective reflexivity and
complexity.
Collective reflexivity is the new power of
complexity.
Collective reflexivity will exist if the system
will be rebuilt on new foundations.
Collective reflexivity appears in anything
against the common sense. Responsibility
lies to everyone and reactions are the
same each time.
The system and the agents are responsible
for reflexivity.
Collective reflexivity is cultivated by
groups and the system itself.
The system is responsible for reflexivity.
The system is consisted of many groups. Non of them. Something else.
Reflexivity is a way to protect common
good and maintain responsibility.
There is lack of solidarity due to personal
ambitions, disinterest and unwillingness
for actions.
Reflexivity is not intensive although the
sector experiences rather sudden changes.
Healthcare sector cannot survive only
through formal rules but also through
deep thinking and ethical regeneration.
Relexivity does not operate effectively or
there is no reflexivity.
Reflexivity works for the benefit of groups
and the society.

EvangelosErgen_ComplexityInHealthcare_Dissertation

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