This is the first blogpost in a series of reflections emerging from a workshop on complex adaptive systems research methods held in Baltimore in June 2014. It was first published on the Future Health Systems website.

Until recently, the dominant view of a health system was as a combination of building blocks — such as human resources, finance and so forth — capable of delivering a package of services. The construction of this kind of health system was seen as relatively straight forward.

However, a number of studies have challenged this view by demonstrating the important influence of context on health system performance. This has stimulated an interest among health system analysts in the application of concepts associated with complex adaptive systems to the challenge of managing health system development and change.

This was the theme of a workshop jointly organised by Future Health Systems and the STEPS Centre in Baltimore in June 2014. The workshop provided an opportunity for an exchange of ideas between people whose focus has been on the analysis of health systems, those involved in systems thinking and the role of modelling and those who bring a social science perspective to the analysis of complex and dynamic contexts.

Although health system actors often have a lot of autonomy, most health systems are highly conservative and their future development is greatly influenced by their historical legacy.

This underlines the importance of institutions and the formal and informal rules of behaviour to the effective functioning of a health system. In most health systems, the performance of health workers is strongly influenced by internalised norms of ethical behaviour. But there is little systematic knowledge about these highly influential norms and beliefs.

Several factors may be contributing to an increased possibility of major health system change. These include:

• Rising expectations of citizens for safe and effective health services
• Emergence and spread of potentially disruptive technologies, such as the rapid development of ICTs and of low cost diagnostic technologies
• Growing political pressure on governments to improve access to health services.

Managers of health system change can draw on lessons from other sectors to analyse the process through which a series of relatively small scale changes eventually add up into a major change in socio-technical regime.

Health system development and change is a highly political process in which struggles between competing interests strongly influence the development pathway that results. That is why an analysis of health system change needs to include a study of the political and economic context. This can include the identification of a number of competing pathways of change and the implications of each for different interest groups, including the relatively poor and powerless.

It will be a long time before it is possible to include institutional rules and beliefs, the emergence and spread of innovative technologies and organisational arrangements and the political struggle between interest groups into an integrated model of a national health system.

Meanwhile, it is important to involve a number of disciplinary approaches in the analysis of health system performance and the management of health system change. Some approaches discussed the workshop included the production of innovation histories and the application of the STEPS pathways approach to the analysis of health system change.