Health Promotion Switzerland

The challenge of complexity

Günter Ackermann, Health Promotion Switzerland

Professionals in health promotion and prevention are faced with many challenges: health promotion (and prevention) actions are generally sophisticated interventions in complex social systems. Health promotion projects are usually implemented in settings where many people and groups interact with each other in many different ways. Furthermore, settings such as schools, businesses and families conduct a lively exchange with their environment resulting in mutual influence. Each setting is a fundamentally unique and complex social system with multi-faceted and dynamic modes of operation and action which are difficult to predict (Wright, 2006).

Health promotion projects in such complex systems are faced with great challenges: outcomes are aimed at different levels of intervention with different time perspectives and chains of effects are diverse and characterized by a great variety of interaction and back loops. These limit the predictability and planning of outcomes and it soon becomes difficult to deduct conclusively to what extent an observed effect is the result of a specific measure (Dörner, 2008). A modest measure might suddenly cause a disproportionately large effect, a well-intentioned action surprisingly provoke resistance. Various side effects are in any case the rule rather than the exception. When we are working in social systems we are therefore invariably faced with high complexity. In health promotion the difficulties are particularly sophisticated: the inter-disciplinary and multi-sector approach and the focus on setting and participation are additional elements that complicate the planning and control of interventions. Furthermore, objectives are usually planned to be attained in the long term which renders the conclusive attribution of effects to particular measures almost entirely impossible.

These particularities of health-promoting interventions, the challenging nature of complex social systems and the difficulties associated with them (Ackermann, Bergman et al., 2009) should not lead us to work in an exclusively reactive way or to dispense with planning or control altogether. It is rather a question of confronting complexity and the resulting consequences with appropriate methodology. In this context, it is particularly important to develop and manage quality with an active approach. Besides assuring quality, securing the resources or implementing an adequate documentation system, the central question is whether and how an organisation or a project team is in a position to deal adequately with the complexity. Are the different perspectives of the various stakeholders appropriately considered? Are there suitable forums for regular discussions of the project’s dynamics and its environment? Is there enough flexibility in the project’s structure and planning to accommodate unexpected developments? Does evaluation take into account the complex interdependencies and dynamics or is it inflexibly set on simplistic and unrealistic impact evidence?

In interventions in complex systems, project management and quality development have two main functions:

  1. A systematic approach provides orientation, helps identify and consider key issues and draws attention to blind spots. Systematisation also creates transparency and is the basis for evaluation and accountability.
  2. Joint discussions allow for reflection and assessment of complex issues from different perspectives and provide the basis for developing a shared understanding of problems, visions and strategies. Joint reflection is essential in projects which claim to have a participatory approach.

The quality system quint-essenz promotes both systematisation and joint discussions and provides the appropriate criteria, checklists, templates and tools. Examples are:

  • the quality criteria which encourage you to discuss your project periodically and thereby identify strengths and potential for improvement;
  • the outcome model which helps to identify complex issues and to justify prioritisations;
  • the equity tools which help you tackle the challenge of hard-to- reach target groups, and
  • the planning and project managing charts will enable you to deal with unforeseen developments without losing sight of the long-term goals and objectives.

Quality development and quality management help you to see complexity not as a threat, but as an exciting challenge. We wish you success in your projects and fun with your joint discussions and reflection!

Outcome models in health promotion and prevention

Lesetipp zu den Herausforderungen durch Komplexität in der Programmentwicklung: Ramalingam, Ben; Jones Harry (2008) Exploring the science of complexity Ideas and implications for development and humanitarian efforts:


Ackermann, Günter; Bergman, Manfred M.; Heinzmann, Claudia; Läubli-Loud, Marlène (2009) Komplexitätsreduktion durch Klassifikationsmodelle in der Gesundheitsförderung und Prävention. In: Kirch, Wilhelm; Middeke Martin und Rychlik, Reinhard (Hrsg): Aspekte der Prävention. Stuttgart: Thieme. 20-29.

Wright, M. T. (2006). Auf dem Weg zu einer theoriegeleiteten, evidenzbasierten, qualitätsgesicherten Primärprävention in Settings. In: Jahrbuch für Kritische Medizin, 43, S. 55-73

Dörner, D. (2008). Die Logik des Misslingens. Strategisches Denken in komplexen Situationen. Reinbek bei Hamburg: Rowohlt. 7. Auflage

Last modification: 16 June, 2011 09:45