Complicated and Complex Systems: What Would Successful Reform of Medicare Look Like?

This paper, written by Sholom Glouberman and Brenda Zimmerman for the Commission on the Future of Health Care in Canada, looks at the health care system in Canada describing it as complex and therefore solutions to its problems are also complex. The authors argue that attempts to intervene have always been complicated as the system was seen as complicated. However, if the system is viewed as complex many of the problems can be overcome.


"This paper begins by distinguishing simple, complicated and complex problems. In simple problems like cooking by following a recipe, the recipe is essential. It is often tested to assure easy replication without the need for any particular expertise. Recipes produce standardized products and the best recipes give good results every time. Complicated problems, like sending a rocket to the moon, are different. Formulae or recipes are critical and necessary to resolve them but are often not sufficient. High levels of expertise in a variety of fields are necessary for success. Sending one rocket increases assurance that the next mission will be a success. In some critical ways, rockets are similar to each other and because of this there can be a relatively high degree of certainty of outcome. Raising a child, on the other hand, is a complex problem. Here, formulae have a much more limited application. Raising one child provides experience but no assurance of success with the next. Although expertise can contribute to the process in valuable ways, it provides neither necessary nor sufficient conditions to assure success. To some extent this is because every child is unique and must be understood as an individual. As a result there is always some uncertainty of the outcome. The complexity of the process and the lack of certainty do not lead us to the conclusion that it is impossible to raise a child." (Glouberman and Zimmerman, 2002)


  • How the Canadian Health Care System Came to Its Present State 4
  • Intractable Choices 7
    • Characteristics of Complicated and Complex Systems 9
  • Case Study 1: France to the Top of the WHO Ranking 13
  • Case Study 2: HIV/AIDS in the Developing World: The Brazil Story 16
    • HIV/AIDS in Developing Countries  – the Underlying Assumptions of a Complicated View 16
    • Brazil’s Approach to HIV/AIDS as a Complex Problem 17
    • Changing the Nature of the Questions in Brazil 20  
  • How Ideas about Complexity Can Be applied to Canada’s Health Care Reform 21
    • Examples of Questions for Canadians Reflecting on Health Care Reform 21
    • How Do We Build on Current Structures and Relationships to Stabilize and Enhance Medicare? 22
    • How Do We Make Everyone More Confident That the System Will Be There Should They Need It? 23
    • How Do We Recognize and Support Efforts to Improve Care? 24
    • How Can We Restore Medicare to Reinforce Canadian Identity? 25 


Glouberman, S., and Zimmerman, B., Complicated and Complex Systems: What Would Successful Reform of Medicare Look Like? Commission on the Future of Health Care in Canada, Retrieved from: