The presentation by Professor David Peters was given at the First Complex Adaptive Systems Training Workshop for CNHDRC, which was held in Beijing, China, from 18-19 July. It explains the basic elements of health systems and how they relate to a complex adaptive systems approach.

1. 1 Health System Elements & ConnectionsJuly 19, 2011David H PetersJohns Hopkins University

2. 2 What Is A System? An interaction of parts and their interconnections that come together for a purpose

3. 3 Health System Actors, Functions and Outcomes People Financing Revenue Generation Risk Pooling Allocation & Purchasing Health Status Service Delivery Public Health Services Ambulatory Care Inpatient Care Protection from Health Impoverishment Input Management Human Resources Knowledge Pharmaceuticals Technology Consumables Capital Trust/Satisfaction Oversight Policy Setting Information, Disclosure & Advocacy Regulation Strategic Partnerships & Incentives The State Politicians Policy-makers Providers Public/Private Informal

4. 4 Who Produces Health?

5. The “Control Knobs” of Public Intervention in Health Systems Financing: how to raise money, pool funds, allocate and pay for health care Organization: who delivers services and manages health systems inputs, and how they are delivered Oversight: how do you regulate and use information to change behavior of key actors 5

6. 6 Health Financing: Key Functions Raising revenues Pooling resources Allocating and purchasing

7. 7 Changes in Organization (who does what, how) Service delivery point (clinics, hospitals) Government administrative area (district) Management unit Profession Community Organization Priority program/disease

8. 8 Oversight Tools in the Health Sector Policy-making Establish & enforce laws & regulations Public disclosure Professional self-regulation Consumer advocates Independent media Independent monitors

9. Effective Regulation in the Health Sector Informal and formal “rules of the game” (incentives) can greatly influence performance Local institutions beyond government can be effective: Consumer’s groups, professional organizations, media Co-production-regulation may be more effective than government enforcement of rules Peters & Muraleedharan (2008). Regulating India’s Health Sector: To What End? What Future? Social Sciences & Medicine 9

10. Summary of Health Systems Models: Common Features (1) 10

11. Summary of Health Systems Models: Common Features 11

12. Making Connections: Systems Thinking The process of understanding how things influence each other in a system 12

13. 13 Systems Thinking:Key Concepts Parts of a system are interdependent Actions have multiple-order consequences Optimizing one part can lead to poor system performance Organizational structures drive behavior Mental models influence actions

14. Making Connections Will changes in one part of health system cause changes in other part of health system Other actors Other functions Outcomes 14

15. 15 Health System Actors, Functions and Outcomes People Financing Revenue Generation Risk Pooling Allocation & Purchasing Health Status Service Delivery Public Health Services Ambulatory Care Inpatient Care Protection from Health Impoverishment Input Management Human Resources Knowledge Pharmaceuticals Technology Consumables Capital Trust/Satisfaction Oversight Policy Setting Information, Disclosure & Advocacy Regulation Strategic Partnerships & Incentives The State Politicians Policy-makers Providers Public/Private Informal

16. Making Connections: Where to look Follow people and organizations (actors) Follow the money Follow the information Ask: How will different actors respond? What will happen to health services? What will happen to health system outcomes, for whom? 16

17. Following people Identify “interests” Motivations, Incentives and Accountabilities Identify “influence” Power, Resources Consider how intervention will affect people: Who will benefit, who will lose Who will “own” 17

18. Stakeholder Analysis Matrix (Example) 18

19. Following money and services Will change in financing affect health services? Volume of services Quality of services Who will provide Who will benefit from services 19

20. Following information Will information affect health services? Quality of services Prices for services Who will provide Who will benefit from services 20

21. Incorporating Complexity 21

22. Model for Understanding Health Systems Changes as Complex Adaptive System 22

23. 23 Summary Systems thinking in health systems involves: Understand health systems actors, functions, principles, purpose Make changes in financing, organization, oversight Look for responses in actors, health services, money, information Monitor effects on intended and unintended outcomes