Scaling up amidst complexity

Community member post by Ann Larson

Ann Larson (biography)

How can new or under-utilized healthcare practices be expanded and institutionalized to achieve audacious and diverse global health outcomes, ranging from eliminating polio to reversing the rise in non-communicable diseases? How can complex adaptive systems with diverse components and actors interacting in multiple ways with each other and the external environment best be dealt with? What makes for an effective scale-up effort?

Four in-depth case studies of scale-up efforts were used to explore if there were different pathways to positively change a complex adaptive system. The analytical approach came from Axelrod and Cohen (1999) Harnessing Complexity. They noted that it was impossible to plan a response to every way a complex adaptive system might act, as there are too many possibilities. They recommended observing what surprises emerge as one intervenes; understanding the causes and effects of those surprises makes it easier to determine how to leverage, suppress or mitigate properties of a complex adaptive system to change its behaviour.

The case studies

Our retrospective case studies were of programs aiming to take high-impact health interventions to scale:

  • Case study 1 – postpartum IUD (intrauterine device) services in India;
  • Case study 2 – integrated community case management of childhood illnesses in Mali;
  • Case studies 3 & 4 – an approach to responding to newborns who have trouble breathing (Helping Babies Breathe) in Malawi and Bangladesh.

The studies drew on interviews with informants at the international, national, subnational, facility and community levels, as well as analysis of project documentation (Larson et al., 2015).

What the surprises revealed

We found scale-up efforts needed at least one of two factors to make a genuine contribution to institutionalizing and expanding a new healthcare practice:

  1. a responsive and adaptive scale-up team that gives hands-on support for change and/or;
  2. positive feedback loops internal to the complex adaptive system (especially by increasing community demand) that accelerate change.

These played out in different ways in the case studies.

Case Study 1

The Indian postpartum IUD scale-up effort relied on an intensely adaptive model designed to produce steady increases in capacity and coverage within the government health system. Jurisdictions and health facilities with low capacity received much more support than those with high capacity. There was an explicit plan to systematically extend the services by successively building capacity at each level.

Surprises involved changes in government policy regarding cash incentives to women adopters and providers for the method, early resistance by some clinicians and lack of confidence on the part of other clinicians. The scale-up team, led by respected clinicians, was able to identify and respond to the last two quickly. Eventually this scale-up project, which had received long term funding, would have to end. Informants said that sustaining the service was going to depend on building community demand. This was happening largely outside of the program, with other non-government organisations marketing postpartum IUDs and the government incorporating postpartum IUDs into its system of incentives.

Case study 2

The scale-up of the community-based child health program in Mali was not particularly adaptive. It involved recruiting and training community health workers to be placed in villages remote from primary health services. Its implementation was top-down and it was, to a large degree, imposed by donors.

Its surprises included a drought, civil unrest and diplomatic tensions as the project was being rolled out, conditions imposed by donors, and the complex interaction between the community associations that own the primary health care clinics and the government health system. But at the critical juncture when the case study was conducted, the real and perceived success had resulted in greater support in communities where capacity and resources were high and the program’s benefits clear.

Equally important, support had increased at the national level, largely because reductions in malaria deaths were attributed to the program. Some form of maintenance and expansion of the program was likely to continue, but with significant adaptations by the government, donors and the community health associations to make the program more sustainable and relevant.

Case studies 3 and 4

The Helping Babies Breathe scale-ups in Malawi and Bangladesh did not produce the desired changes in neonatal care, a surprise finding from evaluations conducted at the end of the project. The cascade training, lack of on-going monitoring and support and the particular challenges in creating community demand for a highly technical intervention were some of the reasons for failure.

However, the political will for addressing a common cause of neonatal mortality was established and in both countries there was interest in integrating the approach into a broader maternal and neonatal agenda. The initial Helping Babies Breathe scale-ups can be viewed as an initial sensitizing of the health care system, creating the conditions for local actors to adapt the intervention and accelerate change.


The findings from the in-depth case studies contribute to understanding how scale-up efforts directly and indirectly create system-wide change by becoming part of the complex adaptive system. The direct influence changes the norms and intrinsic incentives for health care practice through hands-on support by an adaptive scale-up team. Scale-up efforts also trigger positive feedback from community members and decision makers at all levels by changing their norms and expectations, but this process takes time as actors gradually adjust their norms.

An earlier review of 17 nation-wide projects to scale-up six maternal and child health interventions (Larson et al., 2014) – which had led to my interest in complex adaptive systems and scale-up – had found that only half had led to meaningful increases in coverage. Perhaps, in the life of a single effort, system-wide change is the exception rather than the rule. The most effective pathway is through a combination of direct support and the longer and less predictable path of providing opportunities for communities, organizations and actors within the health system to demand and shape the change they want.

What’s your experience been with donor-driven scale-up efforts? Have you found similar or different factors to be important?

The study was made possible through funding from the USAID flagship program on reproductive, maternal, newborn and child health. I acknowledge the important contributions of my co-authors Jim Ricca, Jessica Posner, Robert McPherson, and Anne LaFond, and of Eric Sarriot.

Axelrod, R. and Cohen, M. D. (1999). Harnessing Complexity: Organizational Implications of a Scientific Frontier. Free Press: New York, United States of America.

Larson, A., Ricca, J., Posner, J. and Raney, L. (2014). Lessons Learned from the Scale-Up Experience of Six High-Impact Interventions in Reproductive, Maternal, Newborn, and Child Health. USAID Maternal and Child Health Integrated Program (MCHIP): Washington DC, United States of America. Online:

Larson, A., McPherson, R., Posner, J., LaFond, A. and Ricca, J. (2015). Scaling Up High-Impact Health Interventions in Complex Adaptive Systems: Lessons from MCHIP, Jhpiego: Baltimore, Maryland, United States of America. Online:

Biography: Ann Larson PhD is a demographer and public health researcher. She is a visiting fellow at National Centre for Epidemiology and Population Health, Research School of Population Health at The Australian National University in Canberra, Australia.

Keys to transformation: Interactions of values, rules and knowledge

Community member post by Russell Gorddard, Matthew Colloff, Russell Wise and Michael Dunlop

Adapting to climate change can require profound alterations in environmental management and policy. However the social context of a decision process limits options and resists change, often dooming attempts to adapt to climate change even before they begin. How can decision makers in policy and management more effectively see the institutional and social water they swim in, in order to better drive change?

Values, rules and knowledge (vrk) provide a useful heuristic to help decision makers analyze how the social system shapes their decision context. Put simply, decisions require:

  • knowledge of options and their implications
  • values to assess the options
  • rules that enable implementation.
Figure adapted from original in Gordardd et al. (2016)

Viewing the decision context as an interconnected system of values, rules and knowledge can reveal limits to adaptation and suggest strategies for addressing them (Gorddard et al. 2016).

Values are the set of ethical precepts that determine the way people select actions and evaluate events.

Rules are both rules-in-use (norms, practices, habits, heuristics) and rules-in-form (regulations, laws, directives).

Knowledge is both evidence-based (scientific and technical) knowledge and experiential knowledge.

Decision context is the subset of interacting subsystems that are at play in a particular decision process. One core idea is that the decision context may exclude relevant values, knowledge or rules from being considered in decisions. Adaptation may therefore involve change in the decision context.

Russell Gorddard (biography)

Matthew Colloff (biography)

Russell Wise (biography)

Michael Dunlop (biography)

The vrk heuristic provides a useful reminder of the limits of knowledge alone to change decisions. For example, a study involving other colleagues and led by Suzanne Prober (2017) explored constraints on adaptation decisions in agricultural landscapes of high conservation value. We found that values were the major limiting factor and that knowledge was the least constraining.

Shared recognition of the importance of values and rules, as well as knowledge, can provide a valuable starting point for effective adaptation action. However, the institutions and social systems that define decision processes can be hard to influence. By digging into the interactions among values, rules and knowledge we can describe the societal dynamics that shape decision contexts in a way that helps identify leverage points and develop long term adaptation strategies. If, for instance, we identify that particular values and voices are being ignored or marginalised in the decision making process, then we can ask what aspects of the rule or knowledge system are preventing their inclusion.

Vrk interactions in biodiversity conservation

Biodiversity conservation in Australia provides an example (Dunlop et al. 2013). A narrow focus on threatened species conservation becomes problematic under climate change. When climates are stable, preserving threatened species provides a good umbrella for protecting other important aspects of an ecosystem. If threatened species legislation prevents clearing and development of an urban bushland to protect a rare orchid, the recreation and aesthetic values of this bushland are also maintained. However, under climate change life gets more complicated. The goal of conserving species that are innately vulnerable to climate change may be in conflict with other, more attainable conservation objectives. If the threatened species umbrella fails, then maintaining a healthy ecosystem or the amenity of landscapes may need to be goals that are explicitly pursued in their own right.

How does an analysis focusing on vrk interactions enable transformative adaptation in this case? Let us start with one clear interaction between knowledge and values relating to threatened species. Considerable knowledge from modelling the distributions of threatened species, and the processes that threaten them, has been used to support and reinforce the ethical precept, or value, that threatened species can and should be protected. As a result, much conservation effort has gone into determining how best to optimise the survival of threatened species and alleviate threats. Interactions of values and rules are also evident. The values we assign to threatened species are embedded in federal conservation legislation and policy. For example, the role of the Australian government’s Threatened Species Commissioner is described in values terms: partnering in “the fight against extinction.”

From this baseline, we can start to form questions about the dynamics of the vrk system for conservation. That is, how the decision context came into being, and what social processes maintain support for it and reproduce its key features.

  • Has the legislation and research focus on threatened species affected the way people think about and express their value for ecosystems and biodiversity? And does the focus on expressing value for nature through threats to rare, iconic species in turn reinforce support for threatened species legislation and research?
  • Does the policy and legislation encourage a research focus on threatened species to the exclusion of other important areas such as ecosystem health and functions? And does the focus on threatened species research help shape and reinforce the legislation?
  • Do community, advocates and passionate researchers prize threatened species in part because their presence activates threatened species legislation which then effectively protects places and the full suite of values associated with them such as a healthy native ecosystem and landscape amenity?

While simple, this example illustrates how we can move from diagnosis of the constraints imposed by the decision context towards analyses of the social and political interactions and dynamics that create this context. This systemic perspective allows us to search for stabilising feedbacks and potential leverage points.

  • Is a focus on endangered species locked into conservation practice and, if so, how does it limit future options?
  • What are the opportunities to break down limiting co-dependencies between particular forms of knowledge and particular sets of rules?
  • Does a focus on endangered species provide common ground and mutual support for linking conservation research and policy?
  • Is it possible to use this common ground to start growing research and legislative frameworks that incorporate a broader set of conservation objectives?

Focusing on vrk interactions reveals where and how power is wielded. In the example above we see that power is exercised through the ‘threatened species’ concept. Focusing on the vrk interactions reveals how the concept legitimises certain options and knowledge, and excludes other value and knowledge systems. Having the threatened species concept embedded in legislation makes species-based knowledge more powerful. Looking at power through the vrk lens therefore provides pointers to where power exists that may resist change, and where resources may be directed in order to harness and align existing power to enable change.


The vrk model is not an attempt at an inclusive theory, rather it is intended as an everyday gardening tool—a trowel or a spade—useful for digging into our social systems in situations where we recognise they need to change. As discussed in Lorrae van Kerkhoff’s blog post, Enabling co-creation: From learning cycles to aligning values, rules and knowledge, we are exploring how the vrk model can be used as a tool to help us learn about the societal structures that determine our paths and options in a changing world, and how we can create and choose new pathways. Does this resonate with your experience?

Dunlop, M., Parris, H., Ryan, P. and Kroon, F. (2013). Climate-ready Conservation Objectives: A Scoping Study. National Climate Change Adaptation Research Facility: Southport, Queensland. Online:

Gorddard, R., Colloff, M. J., Wise, R.M., Ware, D. and Dunlop, M. (2016). Values, rules and knowledge: Adaptation as change in the decision context. Environmental Science and Policy, 57: 60–69. Online (DOI): 10.1016/j.envsci.2015.12.004

Prober, S. M., Colloff, M. J., Abel, N., Crimp, S., Doherty, M. D., Dunlop, M., Eldridge, D. J., Gorddard, R., Lavorel, S., Metcalfe, D. J., Murphy, H. T., Ryan, P. and Williams, K. J. (2017). Informing climate adaptation pathways in multi-use woodland landscapes using the values-rules-knowledge framework. Agriculture, Ecosystems and Environment, 241: 39–53. Online (DOI): 10.1016/j.agee.2017.02.021

Biography: Russell Gorddard PhD is an agricultural and natural resource economist by training with research interests in sustainability, adaptation to global change and the relationship between knowledge, values and rules in framing the decision context for adaptation planning and action. He is based at CSIRO Land and Water in Canberra, Australia.

Biography: Matt Colloff PhD is an ecologist and taxonomist by training, a founder member of the Transformative Adaptation Research Alliance and Visiting Fellow at the Fenner School for Environment and Society, The Australian National University in Canberra. His current research is in integrative science to underpin natural resource management and adaptation to global change. Matt is passionate about exploring the influence that people have on landscapes and place and how, in turn, place influences people.

Biography: Russell Wise PhD is a Senior Sustainability Economist in the Climate Risks and Resilience Group, CSIRO Land and Water in Canberra, Australia. He has built and led interdisciplinary teams and research programs to help stakeholders understand and respond to unprecedented global changes in climate, ecosystems and economies. He is one of Australia’s leading authorities in adaptation, particularly in relation to overcoming barriers to long-term decision-making in the face of uncertainty to enable just and efficient outcomes. Key to this has been the development of original effective approaches to collaboratively designing and using original concepts and decision-support tools and processes such as adaptation pathways to support policy, planning and investment decision making with government, non-government, and private agencies in Australia, Papua New Guinea and Indonesia.

Biography: Michael Dunlop PhD is a Senior Research Scientist at CSIRO Land and Water in Canberra, Australia. He works on the intersection between the social, institutional and biophysical dimensions of managing the impacts of transformational climate change. He focuses on helping policymakers and managers understand how climate change affects the challenge of conserving biodiversity and sustaining ecosystem-based livelihoods over the coming century. He works with national, state and local governments, natural resource management bodies and non-government organisations in Australia and globally, developing concepts and processes to help them adapt their management and strategies. His research interest are focused on how people value biodiversity, the factors that constrain and enable the ways that managers and decision makers respond to future climate change, understanding how values, rules and knowledge change and interact to shape available decision options, and adaptation to transformational climate change.

Improving mutual consultation among key stakeholders to optimize the use of research evidence

Community member post by Allison Metz

Alison Metz
Allison Metz (biography)

Processes to support the uptake of research evidence call for each of the key stakeholders to consider the challenges faced by other key stakeholders in making good use of research evidence. When stakeholders have the opportunity to consider perspectives other than their own, they will generally have a broader understanding of the problem space, and, in turn a greater commitment to co-creating prototypes for improving research translation.

Let’s consider a real world example in New York City’s public child welfare system. Continue reading

What’s in a name? The role of storytelling in participatory modeling

Community member post by Alison Singer

Alison Singer (biography)

That which we call a rose,
by any other name would smell as sweet.

That Shakespeare guy really knew what he was talking about. A rose is what it is, no matter what we call it. A word is simply a cultural agreement about what we call something. And because language is a common thread that binds cultures together, participatory modeling – as a pursuit that strives to incorporate knowledge and perspectives from diverse stakeholders – is prime for integrating stories into its practice.

To an extent, that’s what every modeling activity does, whether it’s through translating an individual’s story into a fuzzy cognitive map, or into an agent-based model. But I would argue that the drive to quantify everything can sometimes make us lose the richness that a story can provide. Continue reading

Learning from Google about inter- and transdisciplinary leadership

Community member post by Janet G. Hering

Janet G. Hering (biography)

Like most engineers, the Google leadership had assumed that the leader of an engineering team must be at least as competent technically as the members of the team. As Laszlo Bock described in his 2015 book Work Rules!, however, a data-driven assessment disproved this assumption. The counter-intuitive result of “Project Oxygen” was that having “important technical skills that help advise the team” only ranked number eight in the list of key attributes differentiating the most from the least effective managers.

This is very good news for leaders of inter- and transdisciplinary synthesis projects since it’s highly unlikely that these leaders could have all the subject expertise relevant to their projects. If subject expertise is not the most important characteristic of leadership, then what kind of expertise should leaders have and what kind of roles do they play? How important are leaders and leadership in such synthesis projects? Continue reading

Sharing integrated modelling practices – Part 2: How to use “patterns”?

Community member post by Sondoss Elsawah and Joseph Guillaume

Sondoss Elsawah (biography)

In part 1 of our blog posts on why use patterns, we argued for making unstated, tacit knowledge about integrated modelling practices explicit by identifying patterns, which link solutions to specific problems and their context. We emphasised the importance of differentiating the underlying concept of a pattern and a pattern artefact – the specific form in which the pattern is explicitly described. Continue reading