My pick of readings on scaling up health interventions amid complexity

Santa is planning his holiday reading on scaling up amid complexity.

Santa is planning his holiday reading on scaling up amid complexity.

My last post discussed how I came to the conclusion that it wasn’t enough to describe which strategies were effective in scaling up maternal and child health intervention s throughout a national health system in a low or middle income country.

Public health professionals and scientists have a broad consensus about good practices in taking interventions to scale. The problem was that those principles could not be implemented for many reasons—funding constraints, conflicting ideas of the purpose of the activity, misplaced confidence in the ease of changing practices to name a few.

Why scale-up efforts unfolded as they did seemed an important research question with practical implications. I had a lot of case studies but I needed a theoretical framework to describe and analyse this experience across interventions and settings. That search took me to the concept of complex adaptive systems.

I spent a lot of time reading about this issue. In this post I share the publications that were most significant in shaping my thinking. While my emphasis is on low and middle income countries, I think the same forces are at work in high income countries and certainly in the rural and regional health services I know in Australia.

From the New Republic

You know an idea’s time has come (if not passed) when it shows up in quality magazines. This article from November 2014 by Michael Hobbes in the New Republic asks why big development ideas fail. His answer is that sometimes they do and sometimes they don’t. Contexts are different and so need different solutions.   The “success, scale, fail” phenomenon doesn’t always mean that the initial success was false but that the conditions were not conducive in other sites and no one noticed.

For an overview of issues …

The first academic paper that explicitly addressed scaling up health interventions amid complexity was written only a few years ago. Ligia Paina’s and David Peters ‘ article in Health Policy and Planning (open access) is a great read for its clear descriptions of what characteristics of complex adaptive systems might be relevant for taking health interventions to scale. If you want to know what scale-free networks are then start here.

Something to challenge you …

Complex health systems are about constant change and unpredictability. Adding the enormous challenges of addressing immense health needs, such as poverty and the associated scarcity of skilled health workers, equipment, medicines, and infrastructure, the chance of progress seems almost doomed.

In an ideas-rich 2010 working paper for the World Bank called “preliminary” but is nonetheless cited often, Lant Pritchett and Frauke de Weijer argue there is a dangerous temptation for decision makers and implementers to revert to what they term “wishful thinking”, hoping that doing something is better than doing nothing even if there is no basis for expecting success. Potential consequences (beyond making no health impact) are cynicism, duplicity and a degrading of development assistance and health service improvement.

Something to cheer you up …

Well sort of. Trish Greenhalgh writes about primary health care in the UK as a humanistic professor of medicine and social scientist. She has a series of papers with colleagues on the introduction of national e-medical record systems. Many of the papers have been published in The Milbank Quarterly, including one titled “Why National eHealth Programs Need Dead Philosophers”. My take on her conclusions is that the programs are too complex to be managed in a top-down, cookie-cutter fashion. Good local practices get lost in the bureaucracy and poor decisions at the national level create chaos or are ignored at the coal face.   She puts a lot of confidence in the power of individuals—usually clinicians—who can understand the national policies and the realities of medical practice and make the system work to accommodate both.

We don’t read about individuals making such a difference in scale up programs in low and middle income countries, but I have no doubt they play an equally important role. It is individuals and their relationships with others that push, pull or prevent change in complex adaptive systems. To me that is an encouraging thought.

Some numbers to grab on to while exploring complexity …

Most of the studies I read about scaling up development interventions in complex systems are qualitative, for good reasons. But it is still exciting to read a quantitative piece that comes to similar conclusions. Harvard graduate student Dan Honig has written a paper on what makes development interventions effective. His data set is massive and the hypothesis he investigates, and confirms, is intriguing. For complex projects or in complex environments (such as fragile states) development agencies and government departments within recipient countries that allow project managers autonomy to make decisions are more likely to meet their own objectives. If you have ever had to work by the book you will complete understand this conclusion. This paper and Greenhalgh’s studies make a nice pair.

Lessons from other fields …

Scaling up has been part of business talk for a long time and there are many academic and popular books targeting executives and entrepreneurs. Robert Sutton and Hayagreeva Rao teach at Stanford University. Their engaging book Scaling Up Excellence: Getting to More without Settling for Less has many case studies including ones drawn from health and not-for-profits in the US, Europe and Asia. Many of their conclusions resonated with me. I found their metaphor of “air wars” and “ground wars” to be helpful in understanding two fundamentally different approaches to scaling up. One is the replication model, run from headquarters with precise instructions to all branches on what to do and how to do it. The other is a social change model, empowering branches to find their own path towards a big goal.


That’s enough. I hope you have added one or more of these to your holiday reading list. I plan to read more about changing health systems over Christmas and would love to know your personal favourites.

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