( Program manager/Researcher School of Public Health, University of Western Cape, South Africa)
There is no gardening without humility. Alfred Austin
For over two weeks (since 18 August), members of Emerging Voices for Global Health 2014, with the help of expert facilitation from Bruno Marchal and Peter Hill, embarked on the daunting task of making sense of complexity in general, and health systems complexity in particular. This two part – virtual – discussion aimed at unpacking complexity, and the challenges it poses for research and practice.
It was in the middle of this conversation that gardening as a metaphor to navigating complexity emerged, inspired by Kernick’s (2002) paper entitled ‘The demise of linearity in managing health services.’ Kernick proposed gardening over engineering as a perspective to deal with complexity. While the former emphasizes facilitation and flexibility, the latter is predominantly directive and controlling. The metaphor seems to have struck a chord with some EVs. This piece is a report on the convening of these complexity-gardening enthusiasts.
Laying the foundation
Many EVs found the selection of papers – as an introduction to complexity – interesting, even if some were a bit challenging. The issue of semantics was considered imperative, and comprised the mainstay of the first part of the discussion. This was spurred with recognition of the fact that without common understanding of terminologies, it is quite easy for people to talk past each other. EVs thus tried to shed light on the conflation of concepts such as ‘complicated’ or ‘complex’, which are often used interchangeably in common discourse but have quite different meanings in the complexity literature. EVs found the paper by Glouberman & Zimmerman (2002) entitled ‘Complicated and complex systems: what would successful reform of Medicare look like?’ instructive in this regard.
Effort was made to link this complexity literature back to Health System reality in countries to a certain extent. Throughout the discussion, there was a readiness among EVs to acknowledge complexity in daily practice, and some illustrative examples pertaining to health systems were also shared including the patient-physician relationship and trust, global health architecture, donor-recipient relationship, decision-making spaces, the translation of research to practice, and interventions to NCDs and Ebola. EVs articulated the reasons that account for the complexity of the different examples, akin to attributes of complexity or complex adaptive systems such as the high degree of uncertainty and lack of consensus among actors, multiple actors and interactions, diverse contexts, nonlinearity, emergence, self-organization, human agency, etc.
Dealing with weeds
The second part of the discussion focused on identifying key challenges of complexity for research and evaluation including cynicism towards the concept (and its usefulness for decision makers), and the dominant practice of decontextualizing in research.
Managing expectation and cynicism
EVs noted that while complexity is elevated to grandiose stature and as a panacea for all the troubles in the world in some corners, it is also berated by others as a ‘something-nothing’ with little practical significance, due to its lack of conviction in its claims/recommendations and reluctance to deliver quick fixes. EVs seemed to have sober perceptions of the concept, and posed down to earth questions such as ‘If you were the gardener, how would you suggest a given actor (researcher, evaluator, MOH) responds to a challenge?’
It was reiterated in the discussion that acknowledging the daunting complexity that is inherent in many of our challenges and ventures is not meant to disarm us of any initiative but to direct our agency moving forward with humility- that we cannot anticipate all the eventualities and hence need to move cautiously with a bigger picture in mind, constantly reflecting, learning and adapting. Plesk and Greenhalgh (2001) in their seminal paper entitled ‘The challenge of complexity in health care’ urged: “To cope with escalating complexity in health care we must abandon linear models, accept unpredictability, respect (and utilise) autonomy and creativity, and respond flexibly to emerging patterns and opportunities.”
Local plants tend to be more resilient and thriving
There was agreement on the importance of understanding context, and the perils of efforts in research and practice where decontextualizing is the norm. Being cognizant of local knowledge and tapping local resources, and affording spaces to local actors to deal with intricacies in their context were issues that resonated with EVs.
Capitalizing on harvest failures
It was underscored in the discussion that in many studies, too much emphasis is placed on outcomes without any effort to understand on how the transformation comes about or why it fails to materialize. There is a need to shift the focus towards understanding the process of change and underlying determinants. A closer examination of failures and the root causes can offer valuable insight on how to get it right next time.
Call for more complexity-gardening
EVs underscored the lack of adequate examples in application of complexity concepts for research and practice, and lack of clarity and consensus on tools to undertake this. Hence, the call for more adept complexity gardeners!
We hope the Symposium in Cape Town will offer further opportunities for EVs to engage with more complexity gardening enthusiasts in their journey towards becoming adept complexity gardeners in their own settings.