title: When 'solutions of yesterday become problems of today': crisis-ridden decision making in a complex adaptive system (CAS)--the Additional Duty Hours Allowance in Ghana.
abstract: 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.
authors.affiliation: Ghana Health Service, Greater Accra Regional Health Directorate, PO Box 184, Accra, Ghana. Irene.agyepong@ghsmail.org
authors.forename: Irene Akua
authors.initials: IA
authors.lastname: Agyepong
authors.forename: Augustina
authors.initials: A
authors.lastname: Kodua
authors.forename: Sam
authors.initials: S
authors.lastname: Adjei
authors.forename: Taghreed
authors.initials: T
authors.lastname: Adam
mesh_terms: D039602:After-Hours Care / Q000191:economics*; D003657:Decision Making; D003695:Delivery of Health Care / Q000458:organization & administration*; D005869:Ghana; D006284:Health Plan Implementation; D006291:Health Policy; D008503:Medical Staff / Q000191:economics; D009936:Organizational Innovation; D011050:Policy Making; D012456:Salaries and Fringe Benefits / Q000331:legislation & jurisprudence*