Increasingly, health (and other social) systems are perceived as service ecosystems consisting of interconnected and collaborating stakeholders – patients, practitioners, payers, care providers, industry and government bodies. Before designing or planning a technology, product or service intervention, an innovator or planner will typically map the different stakeholders to determine if the innovation has the potential to satisfy, and align with, their diverse set of goals and needs.
However, the ecosystems metaphor or perspective can be used for much more than stakeholder mapping and needs assessment alone. It can help us to get much deeper and closer to the heart of complex health problems, provide new understanding of their dynamic nature and most importantly, help us to design and intervene with better solutions. It also reveals new opportunities for changing status quo practices and for transforming health ecosystems altogether, rather than merely improving them incrementally. To know how to do so, we must literally go back to nature and first understand more deeply the concept and functioning of natural ecosystems.
Natural ecosystems: Four core concepts
Over a century old, the ecosystem concept is central to the science of ecology, or the study of interactions within and between species, and with their environment. Below, I describe four core natural ecosystem concepts, each of which addresses one of the following questions from an ecological point of view:
- Identification: How do ecologists distinguish individual ecosystems for enquiry purposes?
- Functioning: How do natural ecosystems function?
- Structure: How are natural ecosystems structured internally?
- Adaptation: How do natural ecosystems adapt, sustain and evolve?
Below, I discuss each of the concepts in turn.
1. Identification: How do ecologists distinguish individual ecosystems?
To identify individual natural ecosystems for study purposes, ecologists use just two variables. These are:
- A primary producer species that converts abiotic environmental energy resources (light, water, heat, soil, radiation and others) into food resources through photosynthesis. Most primary producers are either plants, algae or certain water-based invertebrates and, second
- The type of environment that itself determines the amount and nature of energy resources available to the primary producer species.
Using permutations of these two variables, ecologists are able to classify distinct ecosystems that exist in multiple separate locations, each of which is bounded by the shared flow of energy and food resources, starting with the primary producer. For example, the European environmental agency EUNIS distinguishes over 60 different terrestrial and marine natural ecosystems on the continent such as coastal dunes and sandy shores, tundra and coniferous woodland ecosystems.
Ecologists recognise that every natural ecosystem (defined using the two variables) is adjacent and connected to other natural ecosystems. When studying an individual ecosystem, ecologists look into these adjacent ecosystems to identify risk and examine factors that may be affecting the flow of energy resources. For example, the Great Barrier Reef (the world’s largest coral reef ecosystem) is connected to fourteen adjacent ecosystems. These include adjacent estuaries, lagoons and open water ecosystems and also those on mainland Queensland itself, such as heath and shrublands, forest plains, river valleys and coniferous woodlands (yes they do have them in Australia as well as Europe). When trying to understand the decline of the famous coral reef (sadly, 2016 was one of the worst years on record), ecologists have concluded that not only are rising sea temperatures to blame, but also factors arising in adjacent ecosystems. In particular, they have discovered that intensive cattle farming in river gullies in Queensland is causing excess sediment to run-off into the reef waters. These soil deposits are blocking sunlight, smothering marine organisms, affecting essential algae and reducing coral and sea grass growth. With the problem identified, there are now several collaborative innovation efforts underway involving farmers and multiple agencies to minimize cattle grazing damage, control erosion and prevent the run-off.
Next, I describe the second concept, concerning how natural ecosystems function.
2. Functioning: How do natural ecosystems function?
To survive and reproduce, species in natural ecosystems not only compete within their own population, and with other species, but also interact in mutual symbiotic relationships. In these, they share, interact with, integrate and use each other’s resources, in effect co-creating their collective ability to survive and reproduce. When in balance with their environment, these dynamic interactions sustain the ecosystem. Figure 2 provides an idealized view of these forms of species interactions.
Often, resource-sharing interactions occur in what ecologists call, functional service groups. These consist of multiple species sharing resources and provisioning services to other species irrespective of their taxonomic affiliation. From these functional service interactions, with some exceptions, all species involved benefit. For example, in the Great Barrier Reef, ecologists identify 14 fish and 11 coral reef functional groups performing different services, most of which make a positive contribution to overall ecosystem resilience and sustainability. Seen as vital to ecosystem recovery after an environmental or human-created crisis, functional service groups have become an important area of ecological enquiry in recent times. I describe specific examples of functional groups and resource sharing when I discuss the third concept below.
Whether within a single species population, within functional service groups or the whole community of many different species, individual ecosystems function, variously sustain and adapt through dynamic processes of resource sharing and interaction. Indeed, ecologists characterize ecosystems as service systems of multiple species interacting with each other and the resources supplied by their environment. The same is true of health ecosystems, or more correctly health service ecosystems. Multiple health actors share and integrate their own and others’ resources to perform and obtain health services, as I explore further later.
Next, I describe the third ecological concept of value to how we think about complex health system problems. This concerns how natural ecosystems are structured internally.
3. Structure: How are natural ecosystems structured internally?
As well as identifying and classifying individual (and adjacent) ecosystems, ecologists have discerned their internal structure in the form of a hierarchy of species and interactions. Using such a hierarchy, they are able to identify key ecosystem processes and services, study patterns of emergent, adaptive behaviour, and determine the species that play the most important roles in maintaining ecosystem wellbeing and resilience (known as “keystone species”).
There are eight levels in a natural ecosystem hierarchy (Figure 3) with each higher level consisting of a greater number and diversity of species and interactions. Using the Great Barrier Reef ecosystem as an example, I shall now describe each of the eight levels in the hierarchy. There are a lot of fish mentioned in this section, but their interactions are not only fascinating but also useful for how we think about health systems.
Level 1: Inside an individual species
At the lowest level of the hierarchy are the molecular, genetic, protein, cellular, brain (or nerve only in some brainless species) and tissue interactions that distinguish one species from another. These allow ecologists to identify unique species and classify them into taxonomic affiliations. For example, 1400 different coral reef species have been recorded on the Great Barrier Reef, of every shape and colour variety imaginable, and there are an estimated 95 different species of large teeth-bearing parrotfish (a keystone species) that feed off algae and dead coral, and which are preyed upon by other bigger fishes.
Level 2: An individual species
At level 2 are the interactions undertaken by an individual species with their own resources and their environment, such as a female loggerhead sea turtle using its magneto-reception sensing capabilities to locate and return to the beach on which it was born to lay her eggs. All species have some form of sensing capability to detect risks and danger, and adapt when faced with threats to their survival; not all are as sophisticated as being able to return to a breeding ground thousands of miles away, yet all have evolved and been fine-tuned through multiple adaptations over millions of years.
Level 3: Within a population
Level 3 in the hierarchy defines the interactions that occur within the same population of species. They can be between co-operating organisms of the same species such as a school of bumphead parrotfish heading out in the morning to search for algae in live coral, bumping it with their square heads, breaking it off, chewing it and then emitting the fine grains to form the white beach sand we like to lie on, or dream of, on tropical beaches. Often too of course, members of a species compete with one another, vying for food resources (such as highly territorial white tip sharks protecting their space from other white tips) or a mate (male loggerheads expend all their energy competing and do not care to return to the breeding ground).
Level 4: Between populations of two species
Level 4 of the hierarchy consists of more complex interactions between two different populations of species. These occur in four different varieties:
- Competition where separate species compete for resources (for example, sea sponge species compete fiercely with each other for space using toxic chemical warfare. Those with the most deadly toxins, which have evolved over millions of years, have the best ability to survive).
- Predation where one species preys on the other (on the coral reef, lemon sharks like to eat particularly colorful parrotfish and tiger sharksprey on vulnerable, slow-moving sea turtles heading for their nesting site).
- Mutualism where two species both benefit by interacting with each other such as between symbiotic algae and coral, whose relationship is essential to the wellbeing of the entire coral reef ecosystem. The algae (a primary producer species) live within the tissue of coral and facilitate the conversion of dissolved calcium into the calcium carbonate that forms it. The algae create an alkaline environment in which calcium carbonate deposition proceeds easily. Also, they provide a very significant portion of a coral’s energy requirements. In turn the coral provide a stable environment in which the algae can live and grow as well as a constant source of carbon dioxide that is required for photosynthesis. The recent “bleaching” of coral on the Great Barrier Reef has arisen due to the algae becoming intolerant to rising sea temperatures and the cattle eroded sediment run-off, throwing the whole ecosystem out of balance.
- Commensalism where just one species benefits from interacting with another, such as a clownfish enjoying the protection of living in the stinging tentacles of sea anemones.
Level 5: Between a beneficiary species and a functional group
At level 5 of the hierarchy are interactions where one or more species benefits from the services performed by a functional group consisting of multiple other species. For example, a functional group of surgeonfish, angelfishes and rabbit fishes feed on a particular form of algae build-up that can restrict the growth of coral. By removing it, they help the coral (the beneficiary) to establish and flourish. Ecologists identify and distinguish individual functional groups by the service they perform. In this example, the functional group is called “grazers” because they graze on the algae. Another functional group, consisting of multiple species of parrotfish that are more destructive, gnashing at and sometimes damaging live as well as dead coral, are called “excavators”. Other functional groups at work on the coral include scrapers and cleaners. The latter are fish who clean other fish on the edge of the reef, removing parasites and detritus to make their customers healthier and who benefit themselves from eating the unwanted material.
Level 6: Within a functional group
At this level of the ecosystem hierarchy, interactions are becoming more and more complex and less well understood. Here, ecologists are seeking to study the interactions that occur between species in a single functional group performing a service, as well as how changes in these interactions impact other species. In particular, they are keen to understand the impact of a loss of functional group diversity on their service performance and ecosystem effects. To date, this is an underserved area of ecological enquiry but nevertheless its importance is one that health designers should heed. They too must consider the role of functional group diversity in overcoming dominant logic, status quo thinking and the effect of routine practices on outcomes within health service ecosystems.
Level 7: Between functional groups
Getting near the top, level 7 are the interactions between more than one functional group performing different services within a natural ecosystem. Here, ecologists are concerned with understanding the dynamic effects, which may be positive or negative, of the services of individual functional groups on each other, and on the ecosystem as a whole. Some functional groups are co-creative such as the different fish groups that graze excess algae from the coral described at level 5; whereas others are more destructive, such as sea urchin groups that burrow beneath live coral on the reef and dislodge it. When existing in high densities, they can remove large sections of coral leading to a more fragile environment that other functional groups are unable to recover. In a health service ecosystem context, level 5 of the hierarchy guides us to think about the nature and effect of interactions between functional groups or teams, how they collaborate, the degree they are integrated and how the status of their relationship supports or hinders health outcomes. I shall discuss in greater detail later of course.
Level 8: A community and the environment
Finally, at the highest, most complex level of the hierarchy are the interactions within the entire community of all species in the ecosystem, and with their environment. Although complex, using the hierarchical structure, and rather like a scuba diver on the Great Barrier Reef, it becomes possible to dive down from level 8 into the ecosystem to locate specific risk factors and causes of ecosystem decline, reveal important functional service groups, and detect the effects of a loss of diversity on ecosystem resilience. Level 8 offers a whole ecosystem view. It helps ecologists to locate and study critical resource and service interactions within and between species in individual and adjacent ecosystems. With this insight, they can then design strategies for intervention, adaptation, conservation and management. Such strategies are underpinned by the fourth and final core natural ecosystem concept, which I now describe.
4. Adaptation: How do natural ecosystems adapt, sustain and evolve?
Natural ecosystems are in a permanent state of flowing or flux. At any given time, their wellbeing depends on the balance between the amount of needed environmental (energy) resources, the health of the primary producer species, and the diversity of species, populations and functional groups that provision and share services. When the primary producer species is diminished (such as the algae on the reef), then the ability of an ecosystem to recover depends on the diversity, adaptability and functional performance of other species. The more adaptable and diverse the species in an ecosystem, then the greater is its resilience to environmental crisis and perturbations and the higher is the chance of its sustainability.
In a natural ecosystem, species vary in their ability to adapt to changing environmental resources, and to variations in the resources and adaptations of other species. Furthermore, not all organisms within a species adapt equally, have equal capabilities or exhibit the same behaviour; diversity exists within any single species as well as between them. This dynamic interplay between species, resources, (bio) diversity and adaptive capacity forms a central concept for analysing and understanding the sustainability and wellbeing of health systems, a point I shall return to later.
Summary: The natural ecosystem concepts applied
Above, I have described four core concepts in ecological thinking. To summarise, natural ecosystems:
- Are classifiable and distinct, and also adjacent and connected to other ecosystems, where problem root causes may sometimes arise
- Consist of populations and functional groups of species engaged in multiple types of resource interaction, with the services performed by functional groups being especially important in maintaining ecosystem wellbeing
- Have an internal hierarchical structure made up of different configurations of intra-and inter-species resource-interactions; a structure that is useful to break down ecological enquiry and understand patterns and relationships
- Evolve through ongoing resource variation, selection and adaptation, and display varying levels of resilience and sustainability driven by diversity
When applied to health systems, the four concepts together provide health designers with a fuller and more appropriate perspective for identifying root causes, interpreting complex health problems, framing new possibilities, designing strategy and interventions, building novel propositions and transforming value and outcomes.
Design and Transform Value in Health: A Service Ecosystem Framework
To learn how to apply the above concepts to design and transform value in health ecosystems, download my publication, Design and Transform Value in Health: A Service Ecosystem Framework, of which the above is an extract.
To download the publication, visit the Umio website (registration required).
Above copyright Chris Lawer 2016.
 I am hoping you never look at your tropical fish collection in the same way again.
 Unlike the cattle grazing in Queensland, they have a positive effect on ecosystem wellbeing.