Intended for healthcare professionals


Role of politics in understanding complex, messy health systems: an essay by David J Hunter

BMJ 2015; 350 doi: (Published 09 March 2015) Cite this as: BMJ 2015;350:h1214
  1. David J Hunter, professor of health policy and management
  1. 1Centre for Public Policy and Health, School of Medicine, Pharmacy and Health, Durham University, Durham, UK
  1. d.j.hunter{at}

Rather than exclude politics from health, David Hunter argues that we must embrace it if we are to improve our complex health systems

Health systems have always been complex, messy, hard to comprehend and even harder to change. Meeting these challenges has not been helped by the endless meddling in health systems by politicians. In this endeavour they have been assisted by numerous snake oil merchants peddling the latest fads and fashions.1 These are invariably derived from the ideologies of those funding numerous think tanks, and lobbyists engaged in what has been termed institutional corruption2—a case of faith based policies triumphing over evidence.

The political nature of the policy process is therefore central to any understanding of a complex system. It is also why political science is uniquely well placed to explore its inner workings. Largely ignored and unappreciated, the discipline has much to offer those seeking a deeper understanding of current health systems, how they operate, and what needs to occur if they are to undergo effective and sustainable change.

Admitting and appreciating complexity

Although policy makers are now more ready to acknowledge the existence of complexity and complex adaptive systems,3 they lack a true appreciation of them. This may be because they need the systems to fit into “the traditional mainstream of evaluation approaches.”4 The Medical Research Council guidance on developing and evaluating complex interventions, which appeared initially in 2000 and was modified in 2008, is one such example.5

Although the guidance includes a range of social science methods, Ray Pawson, an authority on social research methods, is critical of the remaining shortcomings in the MRC’s limited understanding of complexity.4 Essentially, because it is still wedded to a spurious “scientism,” the attempt to provide an overlay of uniformity and stability on what are unstable and …

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