Embracing a Systems Approach to Health: Why and What It Really Means

The Need for a Historical Paradigm Shift

A reader recently asked some insightful and important questions about the value and meaning of taking a systems perspective in health and healthcare. See the original comment here. Here is my response:

Thank you for raising these thoughtful points. You’re absolutely right that calling for a "systems" approach begs the question: what do we actually mean by system, and why believe it will improve anything in health care? The word can conjure images of top-down bureaucracy, government edicts, and rigid command-and-control structures. If “systems” are just about central control, one might well ask: hasn’t that been tried, and haven’t we seen poor outcomes? And indeed, voluntary interactions – people freely cooperating and innovating – have given us tremendous prosperity in many arenas.

I appreciate this chance to clarify what a systems approach means to me (and to many thinkers in complexity science), especially in the context of health. Far from being a euphemism for heavy-handed government, systems thinking is a way to understand relationships and interactions over time. It has revolutionized my own perspective as an emergency physician stepping back to look at the big picture, but also more localized interactions in families and patient encounters. Let’s explore why “systems” are not inherently the enemy, how they can be bottom-up as well as top-down, and why a systems approach is crucial to solving our health care challenges.

What Is a “System”? (It’s Not Just Government Bureaucracy)

First, let’s demystify the term “system.” In everyday language we do often talk about “the system” and mean a hospital group or some lumbering government or corporate machine. But in systems science, the word has a far broader (and frankly, more interesting) meaning. A classic definition comes from Donella Meadows, one of the pioneers of systems thinking: “A system is an interconnected set of elements that is coherently organized in a way that achieves something.”[1] In other words, any collection of parts that interact to produce some outcome is a system.

By this definition, government is a system – but so is a family, so is a 2nd-grade class, so is a sports team, so is a forest or an ecosystem. Meadows gives examples: “A school is a system. So is a city, and a factory, and a corporation, and a national economy. An animal is a system. A tree is a system, and a forest is a larger system...”[1] Even you and I are living systems (our bodies are made of cells, organs, and feedback loops). In fact, voluntary free-market interactions form a system – the market economy – which is one subject of complexity science.

The Santa Fe Institute, a renowned research center for complexity science, notes that the science of complexity studies how individual elements spontaneously self-organize into complex structures and patterns[2]. For example, simple interactions among individuals can lead to markets, ecosystems, cities, and “order” emerging without a central controller[3]. So, not all systems are top-down. Many of the most robust systems – like ecosystems or the internet or the global economy – are bottom-up, adaptive, and decentralized.

In short, systems are everywhere. The question isn’t whether to have a system (we always will), but whether we understand the systems we’re part of. Systems thinking is about recognizing those interconnections and dynamics so we can work with them (instead of being caught off guard by unintended consequences).

Top-Down vs. Bottom-Up: Control Is Not the Goal

You argue that “systems are top down, command and control” and inherently coercive, whereas “voluntary interaction… generates flourishing.” There’s an important insight here: Over-centralized, rigid control can indeed make systems perform poorly. Interestingly, that is exactly a key lesson of systems theory! Donella Meadows warned that large hierarchical organizations often lose adaptability because feedback gets distorted or delayed through too many layers[4]. Complex systems thinkers frequently point out that brute-force policies can backfire. As Peter Senge famously put it in The Fifth Discipline, one of the “11 Laws of Systems”: “The harder you push, the harder the system pushes back.”[5] In other words, if we try to force a complex system to do our bidding, it often resists or produces perverse results.

So, we are in agreement on this: simple “command and control” approaches often fail for complex problems. A systems approach is not about micromanaging everything from the top. Instead, it’s about learning how to balance top-down intent with bottom-up emergence. It means paying attention to feedback loops, incentives, and information flows in the system so that we can design better policies or better grassroots solutions.

To illustrate, policy (yes, government policy) doesn’t have to mean authoritarian edicts. Good policy can simply set the rules of the game that allow voluntary interactions to flourish without the worst side-effects. For example, a policy might establish that food and drugs must meet safety standards – that’s top-down in one sense, but it empowers consumers and trustworthy businesses in the marketplace. The key is that a healthy system uses feedback and adaptation. In a democracy (an ideal one, at least), policies aren’t meant to be static commands from on high – they should respond to citizen feedback, court challenges, media scrutiny, etc. If our public policies feel like one-way compulsion with no learning or input, that’s a failure of the system’s feedback mechanisms. A systems thinker would indeed criticize that situation and call for more adaptive, participatory approaches.

Complex adaptive systems theory actually celebrates bottom-up self-organization. A huge part of the field is studying how independent agents (whether people, firms, or cells in your body) can produce complex, self-organized behavior without a central planner. The late Nobel laureate Elinor Ostrom, for instance, showed how communities self-organize to manage common resources without top-down regulation. Complexity scientists like Murray Gell-Mann and J. Doyne Farmer (featured in Waldrop’s Complexity book) studied financial markets where no one is in charge yet a sort of order emerges. All this is to say: systems thinking is not a code word for central planning. It often highlights the limitations of central planning, in fact.

So if we agree heavy-handed control is problematic, what’s the alternative? It’s systemic design – finding leverage points where a small tweak can lead to big improvements, or structuring incentives so that the system’s natural dynamics produce better outcomes on their own. This might mean encouraging more bottom-up innovation and feedback within a system rather than issuing more commands. (Donella Meadows’ essay “Leverage Points: Places to Intervene in a System” is a great read on this topic, by the way.)

Why Healthcare Needs a Systems Approach

Now, let’s get specific to health care. You asked, “Why call for a systems approach to health care? Is it not obvious that systems do not produce good outcomes?” In my experience as an ER physician, it’s actually the lack of systems thinking that leads to so many of our poor outcomes. Health care is teeming with brilliant, dedicated people – doctors, nurses, researchers, you name it – all doing their best in their individual spheres. But everyone is focused on their piece: the ER doctor treats the immediate crisis, the primary care doctor manages routine visits, hospital administrators focus on their institution’s metrics, policymakers focus on one law at a time, etc. Who is looking out for the interactions and gaps between all those pieces? Very often, no one.

Our health care “system” (as it’s often sarcastically put in quotes) is actually a collection of fragmented parts that don’t communicate well. Each optimizes for its own goals – often with success – yet the overall results are mediocre. The U.S., for example, spends far more per capita on health care than any other nation but doesn’t have the best health outcomes to show for it. Why? Largely because the parts aren’t coordinated into an efficient whole. It’s profit-driven and episodic (treating one acute episode at a time) rather than preventive and continuous. In systems terms, we have sub-optimization: each component (hospital, clinic, insurer, pharma company, government agency) might be doing what makes sense for them, but the overall system is misaligned with the goal of a healthy population.

A systems approach to health care means widening our lens. Instead of only asking, “How do I treat this one patient right now?” we also ask, “What patterns are causing patients like this to end up in the ER? How do all the players and factors influence each other?” It means recognizing, for example, that social determinants of health (like housing, education, environment) are integral parts of the health system. Currently, those often lie outside the clinic’s purview – but then we end up with hospitals overwhelmed by preventable illnesses. Systems thinking would encourage bridging those silos. (Indeed, I co-authored a paper reviewing how health system frameworks can integrate social determinants[6], because health outcomes emerge from the whole context, not just what happens in the doctor’s office.)

Another concrete example: feedback loops in healthcare finance. In an episodic, fee-for-service model, there’s a feedback loop that can perversely reward more treatment over prevention. The more illness and procedures, the more revenue – that’s a classic case of a system structure producing an unintended outcome (lots of expensive “sick care” rather than affordable wellness care). A systems approach would seek to realign incentives (say, via bundled payments, or community health investments) so that keeping people healthy is rewarded. This is the kind of structural tweak that individual heroic effort can’t overcome if the underlying system incentives are misaligned.

In short, we need someone minding the whole system, ensuring the parts work together towards the outcomes we actually want (healthier people at lower cost). As the saying goes, “Every system is perfectly designed to get the results it gets.” If we don’t like the results, we have to change the design, not just work harder within the design. That’s why I’m so passionate about bringing a systems perspective into health care reform discussions.

Learning from History: When “Voluntary” Isn’t Enough

You rightly celebrate voluntary human interaction for generating prosperity and flourishing – absolutely! Voluntary exchange in markets, private innovation, philanthropy, community initiatives… all these have done wonders. But it’s important to take an honest look at where purely voluntary systems have also fallen short, especially in providing equitable health outcomes.

History gives us some clear lessons. Let’s consider the U.S. health system before major government involvement. Going back to the late 19th and early 20th century (which my book Other Possibilities explores in story form), health care was essentially a voluntary free-for-all. There was amazing medical progress, yes, but access to care was a privilege, not a right. If you had money or charitable benefactors, you might get decent care; if not, you often went without. Marginalized groups – Black Americans, Indigenous people, many women and the poor – were frequently left out or mistreated. For example, in the early 1960s, before Medicare and Medicaid were introduced, less than half of American seniors had any health insurance and most working-class families struggled to afford hospital bills. A single serious illness could wipe out a lifetime of savings[7].

Moreover, that era’s “voluntary” health system was rife with exclusion. African Americans in many regions faced a “separate and brutally unequal” healthcare system under segregation. Thousands of Black patients died every year simply for lack of access to hospitals that would admit them[8]. Dr. Martin Luther King Jr. observed that “of all the forms of inequality, injustice in healthcare is the most shocking and inhumane.”[9] This injustice was maintained by the voluntary choices of hospitals and practitioners in a segregated market, until federal policy (Medicare in the 1960s) used its funding leverage to help force the desegregation of hospitals[10][11]. In other words, government intervention helped correct a market failure there – a failure to treat people equally and ethically.

None of this is to say government always gets it right (it doesn’t). But it shows that relying purely on voluntary action can sometimes entrench injustices or leave many people out. Unfettered systems will produce outcomes – but not necessarily the outcomes we desire as a society (fairness, universality, etc.), because the system’s initial conditions and rules matter.

I remain open-minded about how we achieve goals like health and well-being for all at the lowest cost. My loyalty isn’t to “government” per se; it’s to the outcomes of better health, equity, and efficiency. If a mostly free-market approach can deliver those outcomes, fantastic! If a single-payer government-run model does it better, then that’s what we should choose. In practice, I suspect the best approach will be a hybrid, leveraging the innovation and adaptability of markets and the fairness and coordination that public policy can provide. But no matter what blend of private/public, the quality, feedback, and intelligent design of the system is what will determine success. Good governance (with transparency, accountability, citizen engagement) is as crucial as the extent of governance.

So, to address “Isn’t government just a coercive system?”: Government is indeed a system, and it can be coercive – but it can also be an expression of our collective will to solve problems that individual action alone won’t. The real question from a systems view is: does the system (public, private, whatever mix) have the right checks and balances, feedback loops, and goals in place? A corrupt or inflexible government system is very harmful – and so is a corrupt or unregulated market system that, say, exploits consumers. In either case, the remedy is to change the system’s structure. For instance, if policies are made without citizen input and simply impose rules, the solution is not to have no policies, but to build more democratic feedback into policy-making (public consultations, iterative policy “prototyping,” independent courts to check overreach, etc.). These are all systemic fixes.

Systems Are Everywhere – Let’s Make Them Better

Finally, consider the statement “Systems generate what we see in government and in health care today.” That’s true – but systems also generate everything else we see in society! The achievements of the free market are emergent properties of a system (the economy). The loving support in a family is the product of a little system (the family unit). The success of an open-source software project or a social movement is due to a system of relationships and information flow among participants. We live in a world of systems. We can’t opt out of them, but we can strive to make them work better.

A systems approach isn’t a magical cure-all; it’s just a mindset and toolset. It helps us see the forest for the trees. It urges us to look for root causes and patterns rather than getting lost in isolated events. It reminds us to be humble – complex systems will surprise you (there’s a reason we talk about unintended consequences so much). As David Peter Stroh puts it in Systems Thinking for Social Change, “Today’s problems were most likely yesterday’s solutions.”[12] That rings true in health policy: a well-intentioned fix (say a new payment scheme or a new incentive) might solve one issue but inadvertently create another if we don’t anticipate the system’s response[13]. Systems thinking teaches us to always ask, “And then what happens? And how will different parts of the system react or adapt?”

Crucially, systems thinking also offers hope. If problems are systemic, solutions can be too. By identifying leverage points – strategic spots where a small change can have big effects – we can create positive change that ripples throughout the system. Sometimes this means policy change, but other times it might mean a grassroots innovation that scales up, or a new way of sharing data that allows the whole network to perform better. The common theme is interconnectedness: no part of a complex problem exists in isolation.

My Journey and Perspective (Why I’m So Enthusiastic about This)

I’ll close by briefly sharing where I’m coming from. I’m not just an armchair theorist here; I’m a practicing physician who came to systems thinking the hard way – by seeing the same failures recur and asking “why, why, why?” until I hit systemic causes. Early in my career as an ER doctor, I was struck by how many broader issues (social, organizational, economic) influenced the cases rolling through my trauma bay. That led me back to school for an MPH degree in public health, where I formally studied health systems and complexity science. It was eye-opening – I felt like I finally had words and models (“stocks and flows,” “feedback loops,” etc.) to articulate what I sensed in practice[14][15]. Honestly, I found systems thinking to be a profoundly empowering framework; it turned frustration into curiosity and solutions.

I’ve since taught global health and health systems at the university level and conducted research on these topics. I became the founding co-chair of the American Public Health Association’s working group on systems science and health, and even helped organize a high-level conference at the Rockefeller Foundation’s Bellagio Center in 2012 focused on using complexity concepts to strengthen health systems in low-income countries. (There we saw that central ministries can’t simply dictate improvements – they have to nurture local ownership and system learning. Central actions should enable networks to self-organize toward better health[16][16], rather than try to control everything.) I’ve also been a board member of the International Society for Systems and Complexity Sciences in Health, aiming to spread these ideas in research and practice.

On the research side, I’ve published a number of papers that apply systems thinking to health. For example, in The Lancet we argued for “systems thinking for the [global health] post-2015 agenda,” highlighting that improving health worldwide isn’t just about funding more clinics but about addressing systemic factors and relationships[17]. I’ve written about the Affordable Care Act as a case study in complexity – analyzing how that massive policy reform was influenced by and generated feedback loops in the health system[18]. I’ve explored how to integrate organizational capacity and institutional factors when strengthening health systems in low-income countries[19]. And as an emergency physician, I even wrote about complex systems thinking in emergency medicine – because an ER is a perfect microcosm of a complex adaptive system, with constantly shifting conditions, diverse agents (patients, staff, families), and the need for resilience[20]. (In an ER, rigid protocols only take you so far; success often depends on adaptability, real-time learning, and yes, systems thinking under pressure.)

All of this work comes from a desire to see health care transformed in a fundamental way. I truly believe we can achieve “health and well-being for all at the lowest cost,” but only if we think systemically. That means questioning old assumptions, like the idea that more intervention is always better (sometimes less is more, if we invest in prevention or remove perverse incentives). It means breaking out of silos – for instance, medical care and public health and social services should not be three separate worlds; they’re interrelated pieces of one puzzle. It means focusing on equity and logic in how we organize care: who is left out and why? where are we spending dollars that don’t translate to health? is the system rewarding the outcomes we actually value? These are all systemic questions.

My ongoing Substack book, released scene-by-scene Other Possibilities, is actually a narrative attempt to convey these ideas to a general audience. It’s a true story set in the 1890s about two physicians, which shows how the American health system could have evolved differently. (The title comes from a quote by historian Paul Starr: “The past had other possibilities, and so do we today.”) By looking at the forks in the road – moments where different decisions could have led to a more equitable system – I hope to inspire imagination about what we can do going forward. Each scene of the book is paired with reflections on today’s system and how we might change it. (Shameless plug: Other Possibilities is free to read for anyone interested in a historical-medical drama with a systems thinking twist!)

Further Resources: Diving Deeper into Systems and Complexity

If this “systems approach” idea intrigues you, you’re not alone. There’s a rich literature and community of practitioners dedicated to systems thinking and complexity science. It’s influenced disciplines from ecology to economics to management. Below I’ll list some books and resources that have influenced me, along with links for convenience. Each offers a unique entry point into this way of thinking:

• Thinking in Systems by Donella Meadows: A primer on systems thinking. This is the classic book that clearly explains what systems are, how to map their components (stocks, flows, feedback loops), and identifies common pitfalls and leverage points for change. Meadows’ work is foundational – she brings a gentle, wise perspective that’s very accessible to non-specialists.

• Complexity: The Emerging Science at the Edge of Order and Chaos by M. Mitchell Waldrop: The story of complexity science’s birth. Waldrop is a science writer who chronicles the early days of the Santa Fe Institute and the scientists who first grappled with complex adaptive systems (people like Murray Gell-Mann, John Holland, Brian Arthur, Stuart Kauffman). This book reads like a scientific adventure story, introducing key ideas of chaos and complexity through real personalities. (Fun fact: the Santa Fe Institute, introduced in this book, continues to be a leading hub for complexity research and public education.)

• Edgeware: Insights from Complexity Science for Health Care Leaders by Brenda Zimmerman, Curt Lindberg, and Paul Plsek: A practical workbook for applying complexity in health organizations. This one is especially relevant to health care. It was written in the late 1990s for healthcare managers to understand complexity science. The authors use storytelling and case studies to show how hospitals and health systems can embrace uncertainty, foster innovation at the “edges,” and move away from overly mechanistic management. (It’s essentially a guide on leading change when you can’t control everything – which is always the case in a hospital!).

• Systems Science and Population Health edited by Abdulrahman M. El-Sayed and Sandro Galea: A comprehensive look at public health through a systems lens. This edited volume (by a physician-epidemiologist and an epidemiologist dean) demonstrates how systems science tools – like network analysis, agent-based modeling, and system dynamics – can be used to understand health outcomes on a population level. It covers topics such as how social networks influence health behaviors, how we can model epidemics or health interventions as systems, etc. It’s a great bridge between abstract complexity concepts and real public health issues.

• Complexity: A Guided Tour by Melanie Mitchell: An excellent modern introduction to complexity science. Melanie Mitchell is a professor at Santa Fe Institute, and she manages to make concepts like genetic algorithms, fractals, cellular automata, and network theory understandable and fascinating. The book gives a panoramic tour of how complexity appears in biology, computer science, physics, and social science.

• Embracing Complexity by Jean G. Boulton, Peter Allen, and Cliff Bowman: Understanding complexity as a new worldview. This book argues that we need to shift from the traditional mechanical, linear worldview to a complexity worldview in management and policy. It explicitly challenges the “predict and control” mentality. “Embracing Complexity” shows that in a turbulent, interconnected world, leaders must learn to expect unpredictability and work with uncertainty rather than against it. As one reviewer summarized, this book “presents complexity thinking as a way of understanding how the world works; it challenges the dominant expectation that leaders can control the evolution of the social and organizational world.”[22] It’s both theoretical and practical, with examples from economics, organizations, and international development.

• How Change Happens by Duncan Green: A practitioner’s take on power and systems in social change. Duncan Green (an adviser at Oxfam) combines academic research and firsthand activist experience to explore how social and political change occurs. Notably, his very first chapter is titled “Systems Thinking Changes Everything,” which sets the tone. He emphasizes that change isn’t usually linear or controllable; it involves complex systems where power dynamics, norms, and institutions all interact. This book is very readable and full of real-world stories—from Bolivian indigenous movements to international climate negotiations—illustrating a “power and systems approach” to making change (in fact, that’s how he frames the conclusion: that activists need to think in terms of both power and systems).

• Systems Thinking for Social Change by David Peter Stroh: A hands-on guide for changemakers. Stroh’s book is practically oriented, aimed at people working on tough social problems (poverty, homelessness, education, etc.). It provides tools to apply systems thinking in these contexts. One key message is to move from blame to shared responsibility – recognizing that we are all part of the systems we seek to change. It also cautions against quick fixes. As Stroh writes, “Today’s problems come from yesterday’s solutions”, meaning a well-intentioned quick fix can sow seeds of future problems if we’re not careful[12]. The book introduces system diagrams, archetypes (common patterns like “Fixes that Fail”), and methods for finding high-leverage interventions that create lasting results.

• Understanding Complexity by Scott E. Page (Great Courses lecture series): An engaging audio/video course on complexity. If you prefer learning through lectures, Scott Page (a professor at University of Michigan) has a 12-part Great Courses series that covers the fundamentals of complex adaptive systems in an accessible way. He explains concepts like emergence, adaptation, networks, diversity, and tipping points with vivid examples. It’s a great starting point for those who like a more conversational exploration (and Scott Page is an excellent teacher who infuses some humor too). If you’re looking for one resource to understand complex systems, this is it.

• The Fifth Discipline by Peter Senge: The classic book on learning organizations and systems thinking in management. Senge identifies systems thinking as the “fifth discipline” (after personal mastery, mental models, shared vision, and team learning) that integrates all the others for a learning organization[23][24]. This book had a big impact on business and education when it came out in 1990, and it remains relevant. Senge introduces ideas like the “Beer Game” (a simulation of supply chain dynamics) to show how even well-meaning people, in a poorly designed system, create wild oscillations and bullwhip effects. He also enumerates common “learning disabilities” in organizations (e.g., being too focused on one’s position, or the “illusion of taking charge” by reacting to symptoms rather than underlying structure). Senge’s 11 Laws of Systems (e.g., “Yesterday’s solutions are today’s problems,” “The cure can be worse than the disease,” “Cause and effect are not closely related in time and space,” and “There is no blame”)[25][26] read like poetic distillations of complexity theory. If you’re interested in leadership or organizational change, this is a must-read.

I could go on (there are hundreds more books, institutes, and articles – the rabbit hole runs deep!), but I think that list is a great start for anyone curious. These works come from various domains – ecology, economics, management, public health, etc. – yet they all share a common message: we live in a complex world of systems, and understanding those systems can help us make better decisions and avoid costly mistakes.

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In conclusion, a systems approach to health care isn’t about embracing bureaucracy or rejecting human freedom. It’s about seeing the whole elephant instead of just the tail or trunk. It’s about acknowledging that no element of a complex issue operates in isolation. By applying systems thinking, we can design smarter policies and foster the organic, voluntary innovations that truly improve health. We can also guard against our own best intentions going awry, by anticipating feedback and adapting as we learn.

The outcomes we desire – prosperity, health, flourishing for all – are emergent properties of the systems we build and live in. Rather than turning away from “systems” in disgust, I believe we should embrace the challenge of improving our systems. That involves everyone: government, businesses, communities, and individuals. After all, we are the agents within these systems – our voluntary interactions are what generate the larger patterns. With a systems approach, we make those interactions more informed, coherent, and aligned toward the common good.

Thank you again for prompting this deep dive. Healthy debate is itself a vital part of a well-functioning system (the marketplace of ideas!). I remain genuinely open to varying viewpoints – including skepticism of government – because a core tenet of complexity is that diverse perspectives make a system smarter and more resilient. I hope this explanation clarifies why I find systems thinking so compelling, and why I believe it offers promising avenues to reform health care for the better. We’re all in this complex system together, so let’s figure out how to make it work for us, rather than be working against an unseen tide.

– Chad

AI disclaimer: This post is 100% my ideas, and built on a foundation of decades of my thinking and publications. I did lean heavily on ChatGPT 5 to draft the post after inputting my thoughts and previous work.

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[1] [4] [14] [15] Thinking in Systems – The Key Point

https://thekeypoint.org/2020/09/14/thinking-in-systems/

[2] [3] Complexity | Book by Mitchell M. Waldrop | Official Publisher Page | Simon & Schuster

http://www.simonandschuster.com/books/Complexity/Mitchell-M-Waldrop/9780671872342

[5] [23] [24] [25] [26] The Fifth Discipline - Wikipedia

https://en.wikipedia.org/wiki/The_Fifth_Discipline

[6] [17] [18] [19] [20] Academic Publications | Chadswanson

https://www.chadswanson.com/publications

[7] [8] [9] [10] [11] The Forgotten Role of Medicare in Desegregating US Healthcare | UE

https://www.ueunion.org/ue-news/2020/the-forgotten-role-of-medicare-in-desegregating-us-healthcare

[12] [13] Systems Thinking For Social Change | Summary, Quotes, FAQ, Audio

https://sobrief.com/books/systems-thinking-for-social-change

[16] The mental demands of leadership in complex adaptive systems

https://www.researchgate.net/publication/327169793_The_mental_demands_of_leadership_in_complex_adaptive_systems

[21] What is complex systems science? | Santa Fe Institute

https://www.santafe.edu/what-is-complex-systems-science

[22] Embracing Complexity Book By Jean Boulton

https://www.embracingcomplexity.com/books/embracing-complexity/