Introduction to Complex Health Systems: Course
Outline for Public Discussion (October 2013)
THE CHEPSAA PROJECT
The development of sustained African health policy and systems research and teaching capacity requires the
consolidation and strengthening of relevant research and educational programmes as well as the development
of stronger engagement between the policy and research communities. The Consortium for Health Policy and
Systems Analysis in Africa (CHEPSAA) will address both of these issues over the period 2011 - 2015. CHEPSAA’s
goal is to extend sustainable African capacity to produce and use high quality health policy and systems
research by harnessing synergies among a Consortium of African and European universities with relevant
expertise. This goal will be reached through CHEPSAA’s five work packages:
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assessing the capacity development needs of the African members and national policy networks;
supporting the development of African researchers and educators;
strengthening courses of relevance to health policy and systems research and analysis;
strengthening networking among the health policy and systems education, research and policy
communities and strengthening the process of getting research into policy and practice;
project management and knowledge management.
The CHEPSAA project is led by Lucy Gilson (Professor: University of Cape Town & London School of Hygiene
and Tropical Medicine).
PARTNERS
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Health Policy & Systems Programme within the Health Economics Unit, University of Cape Town,
South Africa
School of Public Health, University of the Western Cape, South Africa
Centre for Health Policy, University of the Witwatersrand, South Africa
Institute of Development Studies, University of Dar es Salaam, Tanzania
School of Public Health, University of Ghana, Legon, Ghana
Tropical Institute of Community Health, Great Lakes University of Kisumu, Kenya
College of Medicine, University of Nigeria Enugu, Nigeria
London School of Hygiene & Tropical Medicine, United Kingdom
Nuffield Centre for International Health and Development, University of Leeds, United Kingdom
Karolinska Institutet, Sweden
Swiss Tropical and Public Health Institute, University of Basel, Switzerland
CHEPSAA WEBSITE
www.hpsa-africa.org
SUGGESTED CITATION
CHEPSAA. (2013). Introduction to Complex Health Systems: Course Outline for Public Discussion (October
2013). Cape Town, Consortium for Health Policy & Systems Analysis in Africa.
This document is an output from a project funded by the European
Commission (EC) FP7-Africa (Grant no. 265482). The views
expressed are not necessarily those of the EC.
2 CHEPSAA: INTRODUCTION TO COMPLEX HEALTH SYSTEMS
CHEPSAA. (2013). Introduction to Complex Health Systems: Course Outline for Public Discussion (October
2013). Cape Town, Consortium for Health Policy & Systems Analysis in Africa.
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October 2013
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CHEPSAA: Introduction to Complex Health Systems
3
This is the first in a series of teaching materials currently being developed by CHEPSAA.
These materials are intended as resources which can be developed and used to enhance
postgraduate teaching and learning related to health policy and systems. The courses are
set at a Master’s degree level, and intended for inclusion within a broader Master’s
programme, but could also be offered as stand- alone short courses.
This document provides a short description and outline of this course, as well as noting
some of the resources which will be available with it, to give a sense of what it will look like
and what it will cover. This outline was developed during, and after, two week-long
workshops held in Cape Town in May 2012 and 2013, in which experienced educators
intensively discussed the curriculum and content. We would appreciate feedback on the
outline as developed thus far, in order to incorporate as much relevant input as possible for
the full course, which is to be available online later in 2013. The full course will include
facilitators’ notes, resources and more detail.
Overall course aim
This course aims to provide an introduction to the components, actors and interrelationships of the health system, as well as core principles of systems thinking and policy
analysis, as a platform for health systems analysis, action and research.
Course description
It is proposed that this would be a course within a Master’s degree programme. It could also
be offered as a stand-alone short course of approximately five days.
As a course within a Master’s programme, it should involve students in approximately 120
hours of study or 12 credits. This estimate is based on the concept of ‘notional hours’ of
learning which is integral to the national qualifications frameworks which some countries
have already implemented, and others are in the process of developing. Within such a
framework, the course would offer 12 credits towards a qualification, which, at Master’s
level, might carry between 120 and 200 credits in total.
A suggested time structure for the course is as follows:
Contact time
3 hour sessions x 10
Non-contact time
Self-study (reading, research, discussion)
Assessment time (assignments, group tasks and
summative assessments e.g. examinations)
Total Course time
30 hours
60 hours
30 hours
120 hours
This time-frame could be adjusted to various delivery models, with more or less contact
time, depending on the different needs of differing situations. Obviously, the more contact
time is offered, the less self-study time will be necessary.
4 CHEPSAA: INTRODUCTION TO COMPLEX HEALTH SYSTEMS
Target audience
The target audience for this course is:
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mid-level managers in the public sector or in NGOs
future health policy and systems analysts and researchers
senior policy makers
academics from other fields of Public Health and beyond.
Although this is an introductory course, providing an entry into the field of health policy and
systems, it is aimed at students who are well qualified and experienced in their own areas of
expertise. They bring this expertise to the course, but must nonetheless learn to use new
ideas and concepts. Some students are likely to come from medical backgrounds and may
be unfamiliar with social science concepts, on which this course is largely based. Others may
be challenged by limited practical experience of health systems. The course is designed to
introduce new concepts but also to allow students to draw on their own experience, and to
provide opportunities for shared, peer learning.
Approach to teaching and learning
The course seeks to develop higher order academic and conceptual skills related to the field.
Where new concepts are introduced, these will be scaffolded in such a way that students
can engage with them iteratively during the course, to build understanding and skills.
A foundation of the course design is the identification and introduction of threshold
concepts. These are the key ideas, set out below, underpinning the course content and
philosophical perspective, with which students should be familiar and conversant.
Threshold Concepts
A. People make sense of the system around them and act based on their understandings
and mind sets.
B. Health systems are socially constructed; they exist within contexts and histories.
C. Health systems are integrative by nature, and consist of complex inter-relationships; we
all have a role in the system.
D. Health systems consist of ‘hardware’ and ‘software’.
E. Health system effectiveness is a ‘whole system’ judgement rather than one based on the
effectiveness of specific interventions.
F. Power is everywhere: in agency, service delivery and decision-making.
G. Everyone has a part to play in the system, working towards shared goals.
H. The health system is knowable and changeable.
I. The health system is a complex adaptive system.
In addition, the mode of learning promoted in the course is based on constructive alignment
of graduate attributes and learning outcomes with learning activities and assessment, so
that the course is consistent and coherent, and its aims transparent. The approach to
learning is also intended to be actively participatory and collaborative; to promote critical,
CHEPSAA: Introduction to Complex Health Systems
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autonomous thinking and learning; to develop analytical and communication skills; and to
encourage a reflective, open-minded approach to health policy and systems. To this end,
the course draws on principles of authentic learning, with tasks rooted in real world
experience and deep learning, in which students are encouraged to think holistically and see
connections and complex relationships. In this way the course provides opportunities for
students to draw on and use their own experience in applying new concepts to real world
examples and settings.
Assessment
The approach to assessment aims as far as possible to include relevant and realistic tasks
that help students to apply the theory and concepts learned on the course, using a range of
thinking and study skills. The tasks are designed to include a variety of assessment methods
and tools which enable students to show their learning on the course. This course will be
assessed through formative assessments (designed to provide students with feedback on
progress and inform further development in the remainder of the course) and summative
assessments (a measure of achievement made in respect of students’ performance in
relation to the intended learning outcomes of the course).
The formative assessment will consist of a portfolio of written tasks which students will
complete individually or in groups and which should be handed in during the duration of the
course. These tasks will comprise of a range of tasks which will practice academic
engagement, writing for specific audiences, application of frameworks and translating
lessons learned in class to students’ own contexts.
The summative assessment will be a written assignment (long essay) deriving from sessions
8 and 9 and drawing on all aspects of the course, which will be submitted at the end of the
course.
In addition, if assessment rules in particular institutions require, students may also need to
sit an examination, as another summative assessment. Details of assessment criteria and
weightings will be suggested when the course is developed more fully.
Course learning outcomes
This course has six learning outcomes. While not all sessions address all of the outcomes,
most of them weave through majority of the sessions, albeit with different weightings in
each session. The introductions to each session outlined below signal the focus of sessions
and their specific aims.
By the end of this course students are expected to be able to:
1. Show understanding of the dynamic and complex nature of health systems by reflecting
on and describing their value bases and functioning, as well as the central roles and
behaviours of a range of actors;
2. Discuss health systems as social constructions, influenced by broader political and
economic forces, generating public value and contributing to societal development;
6 CHEPSAA: INTRODUCTION TO COMPLEX HEALTH SYSTEMS
3. Apply these understandings to assessment of their own health system and comparison
between health systems;
4. Apply relevant analytical skills and an understanding of complex systems in order to
develop ideas about action to strengthen health systems;
5. Develop the personal communication, teamwork and leadership skills which are
important for supporting health system change;
6. Demonstrate understanding of and openness to different perspectives on the nature of
health systems.
Course Outline
The course begins by considering what a health system is and why it is important, and
introducing some frameworks for thinking about health systems. One specific instance of
health system development, the Thai experience, is considered in some detail as an example
of ‘whole system’ improvement - and linked to current international debates around
Primary Health Care and Universal Health Coverage. It then goes on to outline the central
role of people in health systems, their values and mind sets, and why these are important
for understanding of and intervention in health systems.
Throughout the course a number of case studies are used to illustrate and apply concepts
and ideas, and students are encouraged to apply the new ideas to their own contexts as
well. Complex adaptive systems thinking is, finally, introduced as an approach for
understanding and changing health systems.
Each of the sessions outlined below is designed with 2-3 hours contact time, incorporating
lectures and other input (e.g. video and podcast), group and individual tasks and discussion.
After each session students are expected to spend approximately 3-6 hours on reading,
preparation and other personal study.
Note: The full set of materials, which will become available on the CHEPSAA website later in
2013, will provide guidance and resources for activities in each session.
Session 1: Introductions; What is a Health System?
This session aims to orientate students into the course, and provides an introduction to
thinking about health systems, how they are constructed and function in particular contexts,
their value bases and their place in history and society.
Topics and activities :
1. Introductions and course overview: Participatory activity
2. What is a health system and why is it important?: Group work
3. The Political economy of African health systems: Lecture; Podcast on a Nigerian
example; ‘Gap-minder’ review and task
CHEPSAA: Introduction to Complex Health Systems
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Self- study:
a. Reading on introduction to health systems
b. Gather information on timelines of own countries’ health system development
Session 2: Frameworks for describing and analysing health systems and policy
This session fleshes out the discussion of what a health system is and why it is important in a
society. Concepts, measures and frameworks for thinking about systems are introduced and
the integrative nature of health systems is emphasised. Students then apply these to their
own country’s health system. The session also introduces reflection on teamwork skills.
Topics and activities :
1. Students’ discuss own countries’ health systems histories and make comparisons
between them: Group discussion and feedback;
2. Understanding systems: Flashmob Game
3. Ideas and frameworks for thinking about health systems and policy: Video and lecture;
group discussion.
4. Application of frameworks to specific country scenarios: Thinking pairs to prepare for
homework
5. Readings and discussion: what makes for effective group work?
Self-study – Application of frameworks to own country health system
a. Draw diagram of your own health system and reflect on its values base
b. Portfolio task 1: Apply health systems frameworks to analyse own countries’ health
system
c. Read Thai case study with guiding questions
Session 3: Understanding the Thai experience of health system development
This session deepens the ideas about what health systems are: that they are complex and
integrative, and that health system development is a long-term task, influenced by broader
political, economic and social forces, and requiring persistence, vision and adaptability. It
introduces the notion of system effectiveness, and relevant indicators. It uses a case study
of Thailand to develop ideas about understanding and strengthening health systems,
including the interactions between system hardware and software. It encourages personal
reflection on teamwork skills.
Topics and activities :
1. Review reading of Thai case study: Individual reading
2. Thai case study as an example of health systems strengthening: Discussion in group,
class discussion
3. Lecture: wrap-up of the Thai experience
8 CHEPSAA: INTRODUCTION TO COMPLEX HEALTH SYSTEMS
Self-study
a. Reflection on group work and own contribution
b. Personal thinking: What are you learning from the Thai case study about
opportunities for HS strengthening in your country?
c. Read in preparation for session 4
Session 4: Whole system change – Primary health Care (PHC) and Universal Health
Coverage (UHC)
This session develops further and consolidates ideas about what systems are and how to
strengthen them. It focuses on primary health care and universal health coverage as
changes affecting all aspects of the health system. It then asks students to apply lessons
from the Thai case study as well as UHC and PHC to think about and articulate concise ideas
about strengthening key elements of their own country’s health system by writing a policy
briefing note as an exercise in communication.
Topics and activities:
1. PHC and UHC as ‘whole systems’ change’: lecture and discussion.
2. Lessons from Thai experience and UHC/PHC debate for own country health systems:
individual work, thinking pairs, plenary discussion
3. What is required for developing a policy briefing?: Lecture, Input/handout
4. Develop a policy brief on an aspect of Thai experience for own health system:
preparatory brainstorming exercise
Self-study:
 Portfolio task 2: Develop a policy briefing note on strengthening an aspect of own
health system environment, learning from Thai experience.
 Guided reading of one of a range of papers on people in systems – with a focus on
actors and decision-making
Session 5: Recognising agents in health systems
This session focuses on the central role of people and their roles in health systems. It
focuses on the importance of people’s values and mind sets, agency and power, as drivers
of their behaviour and that all these impact on how health systems function.
Topics and activities:
1. Readings about people in systems: Group discussion of range of papers; plenary
discussion
2. Systems dynamics - getting to people in the system: Squaring the circle exercise
3. What drives health system actors?: Lecture and plenary discussion
4. Overview of stakeholder analysis: Brief input
Self-study:
a. Read stakeholder analysis scenario
b. Readings to support reflection on the concepts introduced in the session, particularly
CHEPSAA: Introduction to Complex Health Systems
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power, and its influence over health system change.
Session 6: Exploring power, agency and mind sets
The focus of this session is on applying the ideas from session 5 and thinking about the roles
of health system actors in relation to the process of system change. It looks at actors’
values, beliefs, mind sets, and power relations, and considers how behaviour and attitudes
influence system performance. It then considers the significance of the different views
actors have of health systems and the world, for health systems development, reflecting
also on the interaction between system software and hardware.
Topics and activities:
1. Stakeholder analysis in practice: Group exercise using actor maps based on budgeting
scenario; de-briefing
2. Different paradigms of knowledge: Read and re-discuss papers on people in systems,
hardware-software etc.
3. Re-thinking about actors in own contexts, their location, power and mind sets: Thinking
pairs.
Self-study
a. Portfolio task 3: Write up responses to papers discussed in session, focusing on
people in systems, their different values, paradigms of knowledge; Thoughts on
implications for managing change.
b. Reading for session 7
Session 7: Managing change in health systems
The main aim of this session is to introduce ideas for understanding and managing actors in
health system change. Using a range of analytic frameworks it will focus on complexity and
agency, but also, the understanding that health systems are knowable and changeable.
Students will begin to develop strategies which support intervention and change in systems.
Topics and activities:
1. Managing agents and change: Discussion of readings; lecture (commitment planning;
small wins, sense-making)
2. Managing agents and commitment planning: Group task developing strategies for
managing change using SHA scenario; feedback discussion
Self-study
a. Portfolio task 4: take forward thinking about strengthening own developed in policy
briefing note incorporating ideas from this session: developing strategies for change
in own environment.
b. Guided reading of allocated case studies in preparation for next session.
1 CHEPSAA: INTRODUCTION TO COMPLEX HEALTH SYSTEMS
0
Session 8: Intervening in health systems – case studies 1
This session starts to pull together all the strands of the course, by taking an in-depth look at
a range of case studies of health systems’ change. Sessions 8 and 9 will talk to the
integrative and dynamic nature of health systems, the centrality of actors in shaping these
systems, and opportunities for generating change through addressing both the hard and the
soft aspects of systems. The sessions will require teamwork skills.
Topics and activities:
1. Review reading of case studies: Group reading and discussion
2. Health system strengthening – what the case studies reveal: Guided group discussion
and activities based on specific case study.
3. Input and discussion of skills for making presentations: Buzz groups; group discussion
Self-study
a. Prepare group presentation for next session.
Session 9: Intervening in health systems– case studies 2
This session continues the in-depth look at case studies and what they reveal about health
policy and systems in practice, calling for the ability to demonstrate an understanding of
health systems’ contribution to public value and societal development. The session will also
require presentation and team work skills, and allow reflection on both. The group
presentations will be marked by students in class (as a peer assessment), and the marks will
become part of the portfolio and the formative assessment marks.
Topics and activities:
1. Presentation of case studies: Group presentations and feedback
2. Cross case review of experiences; implications for action in and across cases: Plenary
discussion
3. Reflection on teamwork and leadership in relation to the group task: Plenary discussion
Self-study
a. Portfolio task 5: Write guided reflection on learning from the case study group work,
task and presentation.
b. Reading on CAS in preparation for session 10
Session 10: Health system complexity and change
The final session aims to wrap up the course by deepening the understanding of complex
adaptive systems and linking this understanding to the different concepts, frameworks and
ideas introduced in the course. The session will place particular emphasis on the analytic
skills of students in being able to apply new concepts in different contexts, and on
communicating ideas and understandings to an audience.
Topics and activities:
1. Discussion of papers applying complex adaptive systems (CAS) thinking and concepts to
CHEPSAA: Introduction to Complex Health Systems
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health systems: Student-led journal club
2. Application of CAS concepts to case studies discussed in sessions 8 and 9: Group
discussion.
3. Linking CAS thinking to core concepts discussed in the course: Wrap-up lecture and
discussion
4. Course evaluation: Group discussion; individual written task
Self-study:
Assignment: Write a long essay based on the case studies and presentations of sessions 8
and 9. Detailed instructions to follow. This assignment will form the summative assessment
and will be submitted one week after session 10.
Alignment of assessment to learning outcomes
Assessment item
Learning Outcome to be assessed
FORMATIVE ASSESSMENT
Portfolio task 1: (Session 2)
Apply health systems frameworks to
analyse own countries’ health system
LO 1: Show understanding of the dynamic and
complex nature of health systems by reflecting on
and describing their value bases and functioning,
as well as the central roles and behaviours of a
range of actors.
LO 2: Discuss health systems as social
constructions, influenced by broader political and
economic forces, generating public value and
contributing to societal development;
LO 3: Apply these understandings to assessment
of your own health system and comparison
between health systems
Portfolio task 2: (Session 4)
Develop a policy briefing for
strengthening an aspect of own health
system.
LO 4: Apply relevant analytic skills and an
understanding of complex systems in order to
develop action to strengthen health systems;
LO 5: Apply communication, leadership and
teamwork skills in order to develop action to
strengthen health systems
Portfolio task 3: (Session 5)
LO 4: Apply relevant analytic skills and an
understanding of complex systems in order to
develop action to strengthen health systems;
LO 6: Demonstrate understanding of and
openness to different perspectives on the nature
of health systems, by expressing these in writing
or orally.
Write up responses to papers
discussed in session, focusing on
people in systems, their different
values, paradigms of knowledge;
Thoughts on implications for managing
change.
1 CHEPSAA: INTRODUCTION TO COMPLEX HEALTH SYSTEMS
2
Portfolio Task 4: (Session 7)
Take forward thinking about
strengthening own developed in policy
briefing note incorporating ideas from
this session: developing strategies for
change in own environment.
Portfolio task 5: (Session 9)
Write guided reflection on learning
from the case study group work, task
and presentation.
Group presentations in session 9 will
be marked by peers and marks
included in formative assessment
mark.
LO 3: Apply understandings of the complex and
socially constructed nature of health systems to
assessment of your own health system and
comparison between health systems
LO 4: Apply relevant analytic skills and an
understanding of complex systems in order to
develop action to strengthen health systems
LO 1: Show understanding of the dynamic and
complex nature of health systems by reflecting on
and describing their value bases and functioning,
as well as the central roles and behaviours of a
range of actors.
LO 5: Apply communication, leadership and
teamwork skills in order to develop action to
strengthen health systems
LO 6: Demonstrate understanding of and
openness to different perspectives on the nature
of health systems, by expressing these in writing
or orally.
LO 1: Show understanding of the dynamic and
complex nature of health systems by reflecting on
and describing their value bases and functioning,
as well as the central roles and behaviours of a
range of actors.
LO 5: Apply communication, leadership and
teamwork skills in order to develop action to
strengthen health systems
LO 6: Demonstrate understanding of and
openness to different perspectives on the nature
of health systems, by expressing these in writing
or orally.
SUMMATIVE ASSESSMENT
Assignment: Write a long essay based
on the case studies and presentations
of sessions 8 and 9. Detailed
instructions to follow. This assignment
will be submitted one week after
session 10.
CHEPSAA: Introduction to Complex Health Systems
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