Ghana Health Service, Greater Accra Regional Health Directorate, PO Box 184, Accra, Ghana.
Health Policy Plan. 2012 Oct;27 Suppl 4:iv20-31. doi: 10.1093/heapol/czs083.
Implementation of policies (decisions) in the health sector is sometimes defeated by the system's response to the policy itself. This can lead to counter-intuitive, unanticipated, or more modest effects than expected by those who designed the policy. The health sector fits the characteristics of complex adaptive systems (CAS) and complexity is at the heart of this phenomenon. Anticipating both positive and negative effects of policy decisions, understanding the interests, power and interaction between multiple actors; and planning for the delayed and distal impact of policy decisions are essential for effective decision making in CAS. Failure to appreciate these elements often leads to a series of reductionist approach interventions or 'fixes'. This in turn can initiate a series of negative feedback loops that further complicates the situation over time. In this paper we use a case study of the Additional Duty Hours Allowance (ADHA) policy in Ghana to illustrate these points. Using causal loop diagrams, we unpack the intended and unintended effects of the policy and how these effects evolved over time. The overall goal is to advance our understanding of decision making in complex adaptive systems; and through this process identify some essential elements in formulating, updating and implementing health policy that can help to improve attainment of desired outcomes and minimize negative unintended effects.
政策（决策）的实施有时会被系统对政策本身的反应所阻碍。这可能导致与政策设计者预期的相反、意外或效果不如预期。卫生部门符合复杂适应系统（CAS）的特点，复杂性是这一现象的核心。预测政策决策的积极和消极影响，了解多个行为者的利益、权力和相互作用；并为政策决策的延迟和远距离影响做好规划，这些对于 CAS 中的有效决策至关重要。未能认识到这些要素往往会导致一系列简化方法的干预或“修复”。这反过来又会引发一系列负反馈循环，随着时间的推移使情况进一步复杂化。在本文中，我们使用加纳额外工作时间津贴（ADHA）政策的案例研究来说明这些观点。我们使用因果关系图来剖析政策的预期和非预期影响，以及这些影响是如何随时间演变的。总体目标是提高我们对复杂适应系统中决策的理解；并通过这个过程，确定制定、更新和实施卫生政策的一些基本要素，以帮助实现预期结果，并最大限度地减少负面意外影响。
