Recognising agents in health systems…and complexity
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Agents in health systems include patients, health providers, public and private organizations, and other sectors. These agents can play multiple roles and be influenced by mindsets, interests, power, and organizational context. The behavior of agents is unpredictable and can influence health system change in both positive and negative ways. Change emerges from the complex interactions between agents operating within dynamic environments. How agents exercise discretionary power and respond to interventions shapes whether feedback loops in the system are virtuous or vicious.
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Recognising agents in health systems…and complexity
- 1. Recognising agents in health systems …. and complexity ICHS 5 www.hpsa-africa.org @hpsa_africa www.slideshare.net/hpsa_africa Introduction to Complex Health Systems
- 2. Recognising agents in health systems …. and complexity • Who are they? • What influences their behaviour? • What power do agents have? • What implications for system functioning?
- 3. Going back to the people & software of health systems
- 4. Who are the system agents?
- 5. Categories of people & organisations • Patients & citizens • Health providers & managers at various levels, & other health ‘organisations’ • Public, NGO, & private- for profit organisations • Various levels/groups/units in ‘collective mediator’ • Other sectors • Professional associations • Trade Unions • Research groups • Who else??
- 6. In public service organisations, who ... • controls resources? • has political influence (including media, pressure groups)? • has involvement in the service delivery process? • has impact on wider environment of organisation (e.g. regulatory bodies, local authorities)?
- 7. Agents in Systems May play several system roles, • have relationships with other individuals • be part of groups, and/or work within organisations, with their own histories of experience – which are part of bigger systems e.g. the District Health System • be located in specific ‘settings’, with their own histories
- 9. 1. Mindsets, assumptions, beliefs
- 10. How many fs? two of the most powerful and effective of all human fears are the fear of failure and the fear of success
- 11. http://www.theinvisiblegorilla.com/videos. html Use ‘the Monkey business illusion’
- 12. Observable data and experiences I select data from what I observe I adopt beliefs, draw a map I make assumptions based on these meanings I add cultural and personal meanings Reflexive loop our beliefs influence our selection I take actions based on my beliefsThe Ladder of Inference Conclusion: opinion reached Interpretation: meanings & assumptions added Selected data: what you choose Observable data: what people actually said and did
- 13. Setting Institutions Interpersona l relations Individual capacities Observation Pawson, 2006 Personal experience Views of others Accepted ways of doing things Communication processes Layers of setting: Society, Organisation Context as filter
- 14. Organisational influences Visible: the formal organisation Vision, Mission, Structure, Job descriptions, Goals, Strategies, Operating policies complicated Invisible: the informal organisation Power and influence patternsGroup dynamics Impulsiveness Feelings Interpersonal relations Organisational culture Individual needs complex Adapted from Kusek et al. 2013
- 15. Personal & cultural meanings • Discuss examples from papers
- 16. Sensemaking ‘the process individuals undertake as they try to understand what is going on around them, as they try to make sense of events and experiences’ (Balogun 2003)
- 17. 2. Interests
- 18. Interests • Thing for/about which one has concern e.g. power or status or financial gain, fear of loss • Interests shaped by: – personal values & factors – memories of similar policy experiences – group loyalty – organisational factors – socio-political, socio-economic factors • Influence responses to change
- 19. Reflection point • What is your primary position in the health system? • In that position, what are your interests? – Personally and/or Professionally
- 20. 3. What power do agents have?
- 21. Reflection point • What is your primary position in the health system? • In that position, what is your power? – To do what? – Over whom? • What impact does the exercise of your power have on others around you?
- 22. Power in HS: the view from the bottom National & Provincial Programme & Support Managers Front Line Manager & Provider multiple & sometimes conflicting TOP- DOWN demands Mid- Level Managers hierarchy Local Government and Health Consortium, 2004 Politicians
- 23. Power in health systems From top to bottom From bottom to top
- 24. Discretionary power in organisations exists ‘whenever the effective limits on [the public officer’s] power leave him free to make a choice among possible courses of action and inaction’ (Davis 1969, p.4).
- 25. Everyday discretionary power Overt: • Issuing instructions to others • Publicly refusing to follow instructions • Being rude to patients Covert: • Taking unnecessary sick days • Taking unnecessarily long tea breaks
- 26. Forms of power Over others ‘Involves taking it from someone else, and then, using it to dominate and prevent others from gaining it’ To act “the unique potential of every person and social group to shape their life and world and create more equitable relations and structures of power” With others “finding common ground among different interests and building collective strength Within “people’s sense of self-worth, values and self- knowledge, central to individual and group understanding of being citizens with rights and responsibilities”
- 27. Sources of power Personal Organisational Context: Personal, Group, Organisational, Societal
- 29. Agents influence system change The Dynamic Responses Model Health worker dynamic responses De-jure system De-facto system Formal health system Health system as experienced by patients Ssengooba et al. 2007
- 30. The software matters, in interaction with hardware Hardware: Tangible software: Intangible software: capabilities to commit and engage; adapt & self-renew; balance diversity and coherence Organ- isational hierarchy HR estab- lishment Technology Finance Management knowledge and skills Formal management processes Values & norms Informal rules Relation- ships Comm- unication Adapted from Aragon, 2010
- 31. Pathways of change are unpredictable Health system Intervention
- 32. Virtuous or Vicious feeedback loops? SUPERVISOR PROVIDERS PATIENTS Acceptability & Trust Abusive patient- provider interactions
- 33. Example: South African rural allowance (Ditlopo et al, 2011) Rural allowance introduced 2004, payments awarded retrospectively to July 2003, intended to support rural HR motivation & retention • Impacts? – Some positive impacts on recruitment BUT – Junior nurses felt undervalued and dissatisfied – Impact of financial incentives short-lived & inadequate by selves Why? Low relative to total salary & remoteness not considered; perceived as divisive & not poorly communicated
- 34. Change in complex systems • Change is emergent within organisations – influenced by context; unpredictable, dynamic, non-linear; with unintended consequences that can reinforce or counteract change interventions (Balogun 2006)
- 35. Wrap up: All system agents • Have power to take decisions that influence change in system – are not just robots; have minds of their own! • Operate within contexts that – influence their mindsets – shape their interests & power relative to others • So, organisational change is emergent & unpredictable
- 36. Copyright Funding You are free: To Share – to copy, distribute and transmit the work To Remix – to adapt the work Under the following conditions: Attribution You must attribute the work in the manner specified by the author or licensor (but not in any way that suggests that they endorse you or your use of the work). Non-commercial You may not use this work for commercial purposes. Share Alike If you alter, transform, or build upon this work, you may distribute the resulting work but only under the same or similar license to this one. Other conditions For any reuse or distribution, you must make clear to others the license terms of this work. Nothing in this license impairs or restricts the authors’ moral rights. Nothing in this license impairs or restricts the rights of authors whose work is referenced in this document. Cited works used in this document must be cited following usual academic conventions. Citation of this work must follow normal academic conventions. Suggested citation: Introduction to Complex Health Systems, Presentation 5. Copyright CHEPSAA (Consortium for Health Policy & Systems Analysis in Africa) 2014, www.hpsa-africa.org www.slideshare.net/hpsa_africa This document is an output from a project funded by the European Commission (EC) FP7-Africa (Grant no. 265482). The views expressed are not necessarily those of the EC.
- 37. The CHEPSAA partners University of Dar Es Salaam Institute of Development Studies University of the Witwatersrand Centre for Health Policy University of Ghana School of Public Health, Department of Health Policy, Planning and Management University of Leeds Nuffield Centre for International Health and Development University of Nigeria Enugu Health Policy Research Group & the Department of Health Administration and Management London School of Hygiene and Tropical Medicine Health Economics and Systems Analysis Group, Depart of Global Health & Dev. Great Lakes University of Kisumu Tropical Institute of Community Health and Development Karolinska Institutet Health Systems and Policy Group, Department of Public Health Sciences University of Cape Town Health Policy and Systems Programme, Health Economics Unit Swiss Tropical and Public Health Institute Health Systems Research Group University of the Western Cape School of Public Health