Community Health Systems as Complex Adaptive Systems: Ontology and Praxis Lessons from an Urban Health Experience with Demonstrated Sustainability

In the context of governance of human-environment interactions, a panacea refers to a blueprint for a single type of governance system (e.g., government ownership, privatization, community property) that is applied to all environmental problems. The aim of this special feature is to provide theoretical analysis and empirical evidence to caution against the tendency, when confronted with pervasive uncertainty, to believe that scholars can generate simple models of linked social-ecological systems and deduce general solutions to the overuse of resources. Practitioners and scholars who fall into panacea traps falsely assume that all problems of resource governance can be represented by a small set of simple models, because they falsely perceive that the preferences and perceptions of most resource users are the same. Readers of this special feature will become acquainted with many cases in which panaceas fail. The articles provide an excellent overview of why they fail. Furthermore, the articles in this special feature address how scholars and public officials can increase the prospects for future sustainable resource use by facilitating a diagnostic approach in selecting appropriate starting points for governance and monitoring, as well as by learning from the outcomes of new policies and adapting in light of effective feedback.

After a period of proliferation of disease-specific initiatives, over the past decade and especially since 2005 many organizations involved in global health have come to direct attention and resources to the issue of health systems strengthening. We explore how and why such attention emerged. A qualitative methodology, process-tracing, was used to construct a case history and analyse the factors shaping and inhibiting global political attention for health systems strengthening. We find that the critical factors behind the recent burst of attention include fears among global health actors that health systems problems threaten the achievement of the health-related Millennium Development Goals, concern about the adverse effects of global health initiatives on national health systems, and the realization among global health initiatives that weak health systems present bottlenecks to the achievement of their organizational objectives. While a variety of actors now embrace health systems strengthening, they do not constitute a cohesive policy community. Moreover, the concept of health systems strengthening remains vague and there is a weak evidence base for informing policies and programmes for strengthening health systems. There are several reasons to question the sustainability of the agenda. Among these are the global financial crisis, the history of pendulum swings in global health and the instrumental embrace of the issue by some actors.

In Africa, user fees constitute a financial barrier to access to health services. Increasingly, international aid agencies are supporting countries that abolish such fees. However, African decision-makers want to know if eliminating payment for services is effective and how it can be implemented. For this reason, given the increase in experiences and the repeated requests from decision-makers for current knowledge on this subject, we surveyed the literature. Using the scoping study method, 20 studies were selected and analysed. This survey shows that abolition of user fees had generally positive effects on the utilization of services, but at the same time, it highlights the importance of implementation processes and our considerable lack of knowledge on the matter at this time. We draw lessons from these experiences and suggest avenues for future research.