How do we reframe health performance management within complex adaptive systems?

We need a conceptual framework that situates health performance management within complex adaptive systems.

This is a summary of an important paper by Tom Newton-Lewis et al. It describes such a conceptual framework that identifies the factors that determine the appropriate balance between directive and enabling approaches to health performance management in complex systems.

Existing health performance management approaches in many low- and middle-income country health systems are largely directive, aiming to control behaviour using targets, performance monitoring, incentives, and answerability to hierarchies.

Health systems are complex and adaptive: performance outcomes arise from interactions between many interconnected system actors and their ability to adapt to pressures for change.

In my view, this paper mends an important broken link in theories of change that try to consider learning beyond training.

The complex, dynamic, multilevel nature of health systems makes outcomes difficult to control, so directive approaches to performance management need to be balanced with enabling approaches that foster collective responsibility and empower teams to self-organise and use data for shared sensemaking and decision-making.

Directive approaches may be more effective where workers are primarily extrinsically motivated, in less complex systems where there is higher certainty over how outcomes should be achieved, where there are sufficient resources and decision space, and where informal relationships do not subvert formal management levers.

Enabling approaches may be more effective in contexts of higher complexity and uncertainty and where there are higher levels of trust, teamwork, and intrinsic motivation, as well as appropriate leadership.

Directive and enabling approaches are not ‘either-or’: designers of health performance management systems must strive for an appropriate balance between them.

The greater the dissonance between designing a health performance management system and the real context in which it is implemented, the more likely it is to trigger perverse, unintended consequences.

Interventions must be carefully calibrated to the context of the health system, the culture of its organisations, and the motivations of its individuals.

By considering each factor and their interdependencies, actors can minimise perverse unintended consequences while attaining a contextually appropriate balance between directive or enabling approaches in complex adaptive systems.

The complexity of the framework and the interdependencies it describes reinforce that there is no ‘one-size-fits-all’ blueprint for health performance management.

For higher-order learning and whole-system improvement to occur, practical and tacit knowledge needs to flow among complex adaptive systems’ actors and organisations, thus leveraging the power of networks and social connections (eg, learning exchanges and communities of practice).

Reference

Newton-Lewis, T., Munar, W., Chanturidze, T., 2021. Performance management in complex adaptive systems: a conceptual framework for health systems. BMJ Glob Health 6, e005582. https://doi.org/10.1136/bmjgh-2021-005582l