Anuraj Shankar: Community health and complex systems

My name is Anuraj Shankar. I lead the Community Health Research Unit at the Oxford University Clinical Research Unit in Indonesia.

Right now, one of the key recent research projects ongoing is the SPHERES project, known as the Systematic Public Health Empowerment Research and Education Sites. The purpose of this is to enable all data in primary health care to be interoperable. And this is important because when the data are interoperable, it enables health planners and programme implementers to look carefully and understand what are the gaps in care that may have occurred. Whether it might be an encounter for antenatal care, whether it's an outpatient, somehow if an individual didn't get the care that they were entitled to, to identify that quickly and to take action on that.

The big questions in my field currently are I would say three-fold. One is how to get greater functioning from health systems, how to improve the quality of the care delivery in those. So, if you think of a health system, it's like a living system. It's a complex system of many different interactions. There have been many interventions to improve the quality of health care delivery, and these have typically been one-dimensional. But as a complex system, you have to think about how do you perturb that system, influence it in multiple ways, so in fact it ends up being more robust and resilient to challenge. So really my work is focused on how to achieve that, and the main way that we are doing that now, is we work with health systems, particularly health information systems, and we try to acquire all the information from every primary health care encounter and enable that data to be fully interoperable. Because when those data are interoperable, it means you can look at that in real time, and identify a care gap or a gap in care quality, and take action immediately. So, this ends up being this multi-dimensional real-time intervention that is attempting to enhance healthcare quality again in real time, and training the system to function more effectively.

The same applies actually to other complex systems. So, I also do work in immunology trying to understand the immune system as a complex system. Again, what we typically do is we might provide a vaccination. So, that's sort of a single intervention. But in fact, are there other ways to boost the functionality of the immune system, by a combination of maybe immunisation, maybe probiotics, maybe some other sort of immune therapy. So, these are the things actually, the sort of the next wave of understanding what complex systems are about.

The third complex system (that is very important I think) is of course cognitive development. How does the brain work? How do you learn? How do you potentiate this ability of a child, in a household who's maybe not living under ideal conditions? What are the ways in fact that we can expose that child to different types of nurturing and stimulation, to enhance their cognitive development? So, all three of these are different sorts of complex systems. How to construct these, build these, nurture them, make them more resilient and adaptive. That's really a focus of the work that I'm interested in.

The work that we're doing makes a difference for patients because it makes them more aware of what care they should be receiving, and also aware of the benefits of that care. So, when they go to a health centre or when they go to a worker, a community health worker, they know already, they have some idea of what are the different care packages that they could receive, what the benefits of those actually are. So, they can engage with their health provider. This actually enables them to enhance what's called alliance. Alliance is one of the biggest predictors of success of the interaction between a care provider and a client. So, on that side now, the client is much more engaged in it. That improved alliance enables them to have much better care, in addition to just being aware of the different care packages they're supposed to receive. Now on the other side of it, you have the care provider, whether it's a nurse, a doctor, where that person is also much more aware of the care that they're supposed to provide due to our intervention, because they know various care gaps are going to be identified. And they know they've received care gap specific coaching in the past, and so this enables them to give more effective care. In addition to that, we also teach them specifically how to enhance their alliance on their side with the client. I think all these things together, better understanding of what the carrier is supposed to receive on a level of the client, the level of the provider, and enhancing the alliance between them, so you get this synergistic action.

The type of research that we're doing, it really matters, I think, going forward in the world. Because we're exploring actually two things that are really on the forefront, going forward. Number one is the transition of thinking about humans as primarily biomedical entities, to thinking of them primarily as psychosocial entities, which we are. And a lot of the work that we are doing is exploring how to do that, like I mentioned how do you enhance the alliances. It's not just about what's the intervention that's delivered, but how it really affects the psychosocial factors in a client, how they can improve their own health, how they can think about themselves and enhance their own agency even. So that's one aspect of it. The other aspect of the work that we are doing, is understanding complex systems, particularly in the context of how information is used, and how different types of information actually interact. So, you can see currently AI is so important, right? So, this is all about information and the processing of this, and using that for inference. So, the work that we're doing actually is creating large scale information systems, where all the information coming in can be fully interoperable and used for inference, inference for improved health outcomes in real time. And the other aspect of this, this is very important, is we're using these sorts of interventions, information-based interventions across complex systems to actually assess which sort of information-based interventions actually have an impact. So, really the future of the world is very much, I would say, being shaped by the type of work that we are engaged in. And that's why funders should be interested, because these are the things that are shaping the future. I often say the future is now.

This interview was recorded in September 2025.