Complexity, Healthcare Systems and the Aporias of Healthcare Reform

The First International Conference on Public Policy was a three day conference at Sciences PO in Grenoble that afforded me a unique opportunity to hear about general trends, and cutting edge approaches to public policy analysis. About 900 scholars from around the world attended and, despite the 8 am to 8pm schedule on each of the three days and the beautiful setting, all sessions that I saw were well-attended and usually generated vibrant discussions. I believe that I contributed to both the mission of the conference and the mission of my own university by representing AU at this inaugural event. My own paper was well received, and while there were some hard questions asked about the theoretical approach used (that of Complex Adaptive Systems, or CAS) and its application to health care. On the positive side, one firm conclusion is that complexity theory is a valuable antidote to economic analysis and rational policy models, the value of which is greatest when applied to relationships characterized by high predictability and linearity, but which can produce sub-optimal results when applied in the “zone of complexity”, where consequences of actions are not so predictable and not so prone to agreement. By supplying a methodology (agent-based modeling) that can be used in place of short-term efficiency, complexity analysis can greatly aid health policy decision-makers. On the negative side, the point was stressed that advocates of complexity theory often speak of “rational policy making” and “managerialist approaches” in stereotypical terms, and complexity approaches such as the one sketched in my paper need to accept that there is a place for top-down, as well as bottom –up (or “emergent”) approaches to health care analysis. The over-all result of this activity is that there was widespread agreement that I had demonstrated the promising nature of CAS and complexity theory, but further specification of problems and clearer demonstration of its added value will be needed in the future if this is to become a major paradigm within health policy analysis.Paradoxically, “complexity” in health care systems has spurred both an application of complexity theory to health care organizations and a greater assertion of health care’s essentially political nature. This “increasingly stark dialectic between technical complexity and democratic expectation” ( Fierlbeck, Health Care in Canada: A Citizens’ Guide to Policy: 319) in the health field is part of what lies behind Frank Fischer’s Deweyan call in Democracy & Expertise for more “deliberative forms of interactive inquiry” and promotion of “practical knowledge that brings technical findings together with the political values and social assumptions to which they relate” (2009:6-7). This paper examines the applicability of complexity theory in health care organizations, and reviews such preliminary assessments that are contained in David Kernick’s empirical survey Complexity And Healthcare Organization (2004), Sturmberg and Martin’s, Handbook of Systems and Complexity in Health, (2013) . The paper then draws lessons for health care reform, with due attention to common themes as well as disagreements between analysts and theorists of health care complexity. One firm conclusion is that complexity theory is a valuable antidote to economic analysis and rational policy models the value of which is greatest when applied to relationships characterized by high predictability and linearity