Hospitals as complex adaptive systems: A case study of factors influencing priority setting practices at the hospital level in Kenya

Social Science & Medicine, Volume 174

Edwine Barasa, Sassy Molyneux, Mike English, Susan Cleary , 2016

There is a dearth of literature on priority setting and resource allocation (PSRA) practices in hospitals, particularly in low and middle income countries. Using a case study approach, this paper examines PSRA practices in two public hospitals in coastal Kenya.

Data was collected through a combination of:

  • in-depth interviews of national level policy makers, hospital managers, and frontline practitioners in the case study hospitals

  • review of documents such as hospital plans and budgets

  • minutes of meetings and accounting records

  • non-participant observations of PSRA practices in case study hospitals over a period of 7 months

This paper applies the complex adaptive system (CAS) theory to examine the factors that influence PSRA practices. The findings show that PSRA practices in the case hospitals were influenced by inadequate financing level and poorly designed financing arrangements, limited hospital autonomy and decision space and inadequate management and leadership capacity in the hospital. 

Weaknesses in system ‘hardware’ (resource scarcity) and ‘software’ (including PSRA guidelines that reduced hospitals decision space, and poor leadership skills) led to the emergence of undesired properties. The capacity of hospitals to set priorities should be improved across these interacting aspects of the hospital organisational system. Interventions should however recognise that hospitals are CAS, rather than rectifying isolated aspects of the system, they should endeavor to create conditions for productive emergence.

Journal publication | Governance
Social Science & Medicine, Volume 174