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Performance management in complex adaptive systems: a conceptual framework for health systems
  1. Tom Newton-Lewis1,
  2. Wolfgang Munar2,
  3. Tata Chanturidze3
  1. 1Freelance Health Systems Consultant, Oxford, UK
  2. 2Department of Global Health, George Washington University Milken Institute of Public Health, Washington, District of Columbia, USA
  3. 3Health Practice, Oxford Policy Management, Oxford, UK
  1. Correspondence to Tom Newton-Lewis; tomnewtonlewis{at}


Existing performance management approaches in health systems in low-income and middle-income countries are generally ineffective at driving organisational-level and population-level outcomes. They are largely directive: they try to control behaviour using targets, performance monitoring, incentives and answerability to hierarchies. In contrast, enabling approaches aim to leverage intrinsic motivation, foster collective responsibility, and empower teams to self-organise and use data for shared sensemaking and decision-making.

The current evidence base is too limited to guide reforms to strengthen performance management in a particular context. Further, existing conceptual frameworks are undertheorised and do not consider the complexity of dynamic, multilevel health systems. As a result, they are not able to guide reforms, particularly on the contextually appropriate balance between directive and enabling approaches. This paper presents a framework that attempts to situate performance management within complex adaptive systems. Building on theoretical and empirical literature across disciplines, it identifies interdependencies between organisational performance management, organisational culture and software, system-level performance management, and the system-derived enabling environment. It uses these interdependencies to identify when more directive or enabling approaches may be more appropriate. The framework is intended to help those working to strengthen performance management to achieve greater effectiveness in organisational and system performance. The paper provides insights from the literature and examples of pitfalls and successes to aid this thinking. The complexity of the framework and the interdependencies it describes reinforce that there is no one-size-fits-all blueprint for performance management, and interventions must be carefully calibrated to the health system context.

  • health systems
  • health policy

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  • Handling editor Seye Abimbola

  • Twitter @wolfgangmunar

  • Contributors Each author contributed to the conceptual development of the framework presented and were jointly responsible for manuscript preparation.

  • Funding This framework was developed as part of a Performance Management Model and Landscaping assignment contracted to Oxford Policy Management by the Bill and Melinda Gates Foundation, INV-000955.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.