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

The global health and development field, which has been reasonably dominated by linear models of planning, is witnessing increased interest in complexity, non-linear processes, and systems thinking. This welcome interest is challenged by both language and ability to discern whether complex development phenomena are discussed from the perspective of the nature of particular health systems (ontology), from the identification of more fitting intervention modalities (praxis), or from our approach to learning and evidence (epistemology). This paper is an experience-based contribution to the first two perspectives. Two Bangladeshi municipal health systems provide an example of how sustainable outcomes were achieved through complex adaptive system behaviors, during and after intervention by Concern Worldwide, Inc. (Concern). Concern provided support to the Municipal Health Departments and then assessed the sustainability of health achievements several years after its intervention. We examine complexity in municipal health systems behavior, and the nonlinearity of project effects. We identify ways in which Concern's program, beyond technical design, followed recommendations on leading complex systems towards positive sustainable outcomes. We conclude on the necessity for global community health planners and practitioners to (1) better understand the complexity of the context and issues they are facing, (2) make more reasonable assumptions about the shock to the system'' caused by projects both when they start and when they end, and (3) learn to balance strategic designs with respect for self-organization principles.