OPTIMISING HEALTH

& HEALTH CARE

Using complexity science to prepare for the future

Dr Adrian Schoo, FANZAHPE

What will be discussed
◦ What is meant by a complexity science approach
◦ Relevant issues to consider
◦ What approach can be employed to optimise
health and health care
◦ Who can make a difference
◦ What are the possible barriers
◦ How to progress from here
 Defining complexity science

◦ Complexity science is ‘the study of the dynamics, conditions, and

consequences of interactions within a complex system’ (Mennin 2010; Schoo & Kumar
2018)

◦ Complex phenomena include complex adaptive systems, and are characterised

by diversity, interaction and dependency of elements, the nesting of systems
within others, and self-organisation (Thompson et al. 2016; Schoo & Kumar 2018).
◦ At its core, a complex system is constantly changing, and this requires
permeable boundaries that permit exchange and interaction, and multiple non-
linear interactions and feedback loops (Mennin 2010; Schoo & Kumar 2018).
It’s application explained in health and education
◦ Schoo A, Kumar K. The clinical educator and complexity: a review. The Clinical Teacher. 2018; 15:
287-293 [DOI:10.1111/tct.12757] http://onlinelibrary.wiley.com/doi/10.1111/tct.12757/abstract
(Commissioned paper)
◦ Schoo A. “How to optimise quality health care and equity of access through systems thinking and managing
complexity in different health service sectors”. 1st International Conference on Health (ICOH), 16-17 October
2019, Jakarta, Indonesia.
◦ Schoo A. “Optimising quality of care and equity of access by managing complexity through systems thinking:
Reconciling education and clinical practice with population health and workforce needs, governance and
policy”. 1st International Conference on Health (ICOH), 16-17 October 2019, Jakarta, Indonesia.
◦ Schoo A. “How to Apply Systems Thinking to Improve Health Care System Performance” A systems thinking
approach to manage complexity. ICPH 2019, 23-24 October 2019, Solo, Indonesia.
 A complexity science approach to unpack the issue
◦ Factors associated with sustainable health and wellbeing:
◦ Burden of disease
◦ Health workforce education and training
◦ Preventative and curative health care, and access to these
◦ Lifestyle (nutrition, physical activity, exercise, smoking, alcohol and drugs)
◦ Culture (e.g. organisational), health literacy, mental health risk factors
◦ Environment, building and city design, rural/remote access to quality food
at reasonable prices, employment in local produce,
◦ Climate change, smarter communication and transport
◦ Governance, Leadership, Occupational Health & Safety
◦ E-records, information and other technology, cyber security
◦ Ignorance, groupthink, tax revenue, selfishness/greed
 Global Health Estimates: Life expectancy
and leading causes of death and disability (WHO)

Top 10 global causes of disability-adjusted life years

Top 10 global causes of death in 2019
(DALYs) in 2019

1.Ischaemic heart disease ◦ 1. Neonatal conditions

2.Stroke
3.Chronic obstructive pulmonary disease
4.Lower respiratory infections
5.Neonatal conditions
6.Trachea, bronchus, lung cancers
7.Alzheimer disease and other dementias
8.Diarrhoeal diseases
9.Diabetes mellitus
10.Kidney diseases
◦ 2. Ischaemic heart disease
◦ 3. Stroke
◦ 4. Lower respiratory infections
◦ 5. Diarrhoeal diseases
◦ 6. Road injury
◦ 7. Chronic obstructive pulmonary disease
◦ 8. Diabetes mellitus
◦ 9. Tuberculosis
◦ 10. Congenital anomalies
 Complexity ......
◦ The stakeholders who would likely benefit from
optimal health and wellbeing:
◦ Individuals and their relationships
◦ Communities in the widest sense, incl. their industries
◦ Governments
◦ Global impact
◦ Benefits are likely to include, but are not limited to:
◦ Social and political stability
◦ Sustainability
◦ Productivity
◦ Reduced tax burden
 Complexity .....
◦ Who could possibly benefit from a status quo:
◦ Existing agricultural practices (e.g., costs of changing from
growing sugar cane)
◦ Tobacco industry
◦ Junk food industry
◦ Pharmaceutical industry, manufacturers of medical products
◦ Fossil fuel industry and industries/businesses that rely on it
◦ Individuals (professionals, investors, politicians, decision-makers) who have
financial and or other interests (e.g., privileges) in maintaining status quo
◦ Governments profit from taxes on commodities that are not contributing to
better health
◦ Inequalities between countries, rich and poor, rural and urban
Complexity .....
”Global health as an explicitly political concept taking into consideration
existing inequalities and power asymmetries” (Jens Holst & Razum 2022)

◦ “Overall, the current global health concept fails to adequately consider the global burden of
disease, which is largely determined by non-communicable conditions”.
◦ “Global health goes beyond preventing infectious diseases and health security and must first and
foremost focus on the social, economic, ecologic and political determination of health, which
interacts with non-communicable and communicable diseases, turning them into syndemics”.
◦ “Health-in-all policies in a global perspective are required for sustainably reducing health
inequalities within and between countries, instead of primarily focusing on security and
safeguarding the status quo in a changing world”.
 Complexity .....
”2030 Agenda, health and food systems in times of syndemics: from
vulnerabilities to necessary changes” (Burigo 2021)

◦ “The concept of syndemics contextualizes the COVID-19 pandemic in relation to poverty and social
injustice, as it also reveals the synergy with other pandemics related to the advancement of the global food
system: malnutrition, obesity, and climate change, which all have strong influence of the dominant model of
agriculture”.
◦ “Four strategic concepts to think about the transition towards healthy and sustainable food systems: food
system, food and nutrition security (FNS), human right to adequate food (HRAF) and agroecology”.
◦ “Growing threats imposed by the dominant agricultural model, often denied by powerful economic sectors
and neoconservative groups”.
◦ “Highlight challenges imposed at different scales, from global to local, so that public policies and social
mobilizations developed in the last two decades can resist and reinvent themselves in the construction of
fairer societies”.
 Complexity .....
”Investing preventive care and economic development:
evidences from OECD countries” (Wang & Wang 2021)

◦ “Appropriate prevention is associated with decreases in the prevalence rates of ill health,
which in turn attains sustainable growth in productivity”.
◦ “Too much prevention, however, could lead to higher detection of new chronic diseases
with mild severity, which would result in longer illness duration, and higher prevalence
rates of ill health”.
◦ “With suitable allocation of medical resources, the economic growth rate will help to
cancel out increases in healthcare spending for the elderly and for expenses needed for
the improvement of the population’s health as a whole.”
Who can possibly make a positive difference?
◦ Community members/consumers
◦ Policy makers and other decision-makers
◦ Educators
◦ Professional associations and their members
◦ Business and Industry
◦ Organisations such as NGOs
 How...?
◦ Recognising issues and their relevance
◦ Seeing opportunities rather than threats
◦ Consumer voice and choice
◦ Fostering ownership and accepting change
◦ Leadership in all relevant areas, including:
◦ Recognising the national disease burden, and what measures can reduce this burden most (e.g.,
nutrition, physical activity and exercise, quitting smoking, vaccination, health literacy, stress reduction)
◦ Economics and business (e.g., using price elasticity to influence consumption)
◦ Health system (i.e., more support for preventative health, including mental health)
◦ Education (e.g., health literacy, student/youth education, health workforce education)
◦ Communication, community building, social connectedness, consumer concerns
◦ Incentives for innovation and for doing the right things
What to optimise to achieve better health outcomes
Consumers & Insurers/Governance Professionals & associations/organisations

◦ Preventive health measures (incl. vaccination) ◦ Providing service clarity for consumers
◦ Health and technology literacy ◦ Efficient service models
◦ A voice to provide feedback on service ◦ Interprofessional education and practice
◦ Incentives to maintain optimal health ◦ Use of technology (e.g., telehealth)
◦ ……………………………………………….. ◦ Disincentives for non-essential servicing
◦ ………………………………………………… ◦ ………………………………………………….
◦ ………………………………………………… ◦ …………………………………………………..
◦ ………………………………………………… ◦ …………………………………………………
◦ ……………………………………………….. …
◦ …………………………………………………
 Using complexity: An Australian example
◦ The issue:
◦ Chronic disease burden with a disproportionate number affected in rural and remote Australia (e.g., obesity, diabetes, kidney dialysis)

◦ Contributing factors include:

◦ Unhealthy food items are far more affordable in remote areas than vegetables and fruit
◦ The way in which products are on offer on supermarket shelves and the demand for less nutritious foods

◦ Working towards a solution: A multi-prong approach

◦ Incentives for farmers to change agricultural practices (e.g., growing other crops than only sugar cane)
◦ Utilising price elasticity to influence consumer choice (i.e., higher prices for junk food and lower prices for staple foods)
◦ Some regulation in relation to how products are advertised and displayed by vendors
◦ Stimulating local market gardens (with local employment and associated benefits)

◦ A preventive and curative health perspective:

◦ Education to optimise health literacy
◦ Local infrastructure inviting community members to walk and cycle rather than using elevators and motor vehicles
◦ IPP of the workforce to keep people healthy and to offer best evidence care with reduced waiting lists
◦ Use of technology such as telemedicine to optimise access to health care
◦ Use of technology to enhance access to continuing professional development
 Implications of a complexity science
perspective for systems
◦ Macro (systems) level
◦ Governments (local, regional and national),
policymakers and funders need to recognise
systems-thinking perspectives in making policy and
funding decisions
◦ Adopting a more servant leadership style
◦ Develop policy or funding strategies that are long
term, span jurisdictions and are sustainable
Implications of a complexity science
perspective for the organisation
◦ Meso (organisational) level
◦ Developing a collective awareness about complexity and what this means and looks like
◦ Providing opportunities for collective critical reflection, dialogue and questioning
◦ Leveraging workplace networks and communities as sites in which sense-making, reflection
and inquiry are distributed across a system
◦ Providing incentives (e.g. time and resources) and permission for individuals and teams to find
creative solutions for complexities in their work
◦ Providing organisational and departmental support for continuing professional development
targeted at capability development
◦ Developing a shared vision, values and goals, and empowering people to pursue these
 Implications of a complexity science perspective for the
individual

◦ Micro (individual and team) level

◦ Developing an understanding of complexity and how a complex system is organised and works
◦ Developing personal awareness about one’s role and performance within a complex system can be
unpredictable, interconnected and emergent
◦ Developing an awareness of the many stakeholders within the complex system, and their agendas,
interests and priorities
◦ Reframing challenges and problems as learning opportunities
◦ Looking at the complex system from the inside out and from the outside in
In conclusion: What needs to be taken into account when
working towards optimal future health and health care

◦ Recognise complexity
◦ Being aware of wicked problems
◦ Everything is dynamic
◦ Identify decision-makers and those who influence them
◦ Relationships are important (commonality, win-win)
◦ No predictable outcomes, non-linearity
◦ Permeable boundaries between organisations that permit exchange and
interaction that can assist development
◦ A stepwise progress using win-win approaches
 Some references
◦ Burigo AC, Porto MF. 2030 Agenda, health and food systems in times of syndemics: from vulnerabilities to necessary
changes. Cien Saude Colet 2021 Oct;26(10):4411-4424. [doi: 10.1590/1413-812320212610.13482021].
◦ Greenleaf, R. K. (2002). Servant leadership: A journey into the nature of legitimate power and greatness. Paulist Press.
◦ Holst J, Razum O. Global health and health security - conflicting concepts for achieving stability through health? Global
Public Health. 2022; Mar 8;1-9 [doi: 10.1080/17441692.2022.2049342].
◦ Mennin S. Self-organisation, integration and curriculum in the complex world of medical education. Med Educ
2010;44(1):20–30.
◦ Schoo A, Kumar K. The clinical educator and complexity: a review. The Clinical Teacher. 2018; 15: 287-293
[DOI:10.1111/tct.12757] http://onlinelibrary.wiley.com/doi/10.1111/tct.12757/abstract (Commissioned paper)
◦ Thompson DS, Fazio X, Kustra E, Patrick L, Stanley D. Scoping review of complexity theory in health services research.
BMC Health Serv Res. 2016;16:87.
◦ Wang F, Wang JD. Investing preventive care and economic development in ageing societies: empirical
evidences from OECD countries. Health Economics Review. 2021; 11:18 [doi.org/10.1186/s13561-021-00321-3].
◦ WHO https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates