Open Peer Review Any reports and responses or comments on the article can be found at the end of the article. OPINION ARTICLE Better and fulfilling healthcare at lower costs: The need to manage health systems as complex adaptive systems [version 1; peer review: awaiting peer review] Joachim P. Sturmberg , Johannes Bircher 3 School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Holgate, NSW, 2250, Australia International Society for Systems and Complexity Sciences for Health, Waitsfield, VT, USA Hepatology Department of Biomedical Research, University of Bern, Bern, Switzerland Abstract Rising healthcare costs are major concerns in most high-income countries. Yet, political measures to reduce costs have so far remained futile and have damaged the best interests of patients and citizen. We therefore explored the possibilities to analyze healthcare systems as a socially constructed complex adaptive system (CAS) and found that by their very nature such CAS tend not to respond as expected to top-down interventions. As CAS have emergent behaviors, the focus on their drivers – purpose, economy and behavioral norms – requires particular attention. First, the importance of understanding the purpose of health care as improvement of health and its experience has been emphasized by two recent complementary re-definitions of health and disease. The economic models underpinning today’s healthcare – profit maximization – have shifted the focus away from its main purpose. Second, although economic considerations are important, they must serve and not dominate the provision of healthcare delivery. Third, expected health professionals’ behavioral norms – to first consider the health and wellbeing of patients – have been codified in the universally accepted Declaration of Geneva 2017. Considering these three aspects it becomes clear that complex adaptive healthcare systems need mindful top-down/bottom-up leadership that supports the nature of innovation for health care driven by local needs. The systemic focus on improving people’s health will then result in significant cost reductions. Keywords Healthcare costs, Healthcare financing, Healthcare as complex adaptive system, Sense or purpose of healthcare, Definition of health, Healthcare organization, Norms in healthcare, Complex adaptive systems, System dynamics, Philosophy of medicine 1,2 3 1 2 3 Reviewer Status AWAITING PEER REVIEW 05 Jun 2019, :789 ( First published: 8 ) https://doi.org/10.12688/f1000research.19414.1 05 Jun 2019, :789 ( Latest published: 8 ) https://doi.org/10.12688/f1000research.19414.1 v1 Page 1 of 11 F1000Research 2019, 8:789 Last updated: 05 JUN 2019