MedCity Influencers

At the Crossroads: Examining the complexities of the largest vaccination effort in history

Can we try to peel away the layers to see exactly what it is that makes the world’s largest vaccination rollout so daunting and complex? What is it that defines the level of complexity of a situation?

It has been just over eleven months since the WHO declared the Covid-19 outbreak as a global public health emergency – eleven months in the history of our 4.54 billion year-old planet but an eternity for many of us who have survived a year filled with sorrow, isolation, and extreme uncertainty. The world around us has changed drastically in the past eleven months; many of our assumptions, expectations, and certainties have all been challenged and unceremoniously deconstructed. But most of all, the sheer number of lives lost, and all the hopes and dreams that were extinguished with it, gives the last eleven months a perspective that will last each of us a lifetime. As the saying goes, extraordinary times call for extraordinary measures. And humanity has firmly responded by developing the fastest vaccines to ever be created.

One of the most intriguing aspects about the Covid-19 pandemic and, particularly, the largest vaccination rollout in history has been the level of complexity involved. Regardless of the nation or region of the world one may be from, the complexity of accurately and safely distributing and administering Covid-19 vaccines across vast populations in a time-sensitive manner has got to be one of the greatest challenges facing humanity in 2021. The sheer number of entities, factors, and dependencies involved in this undertaking makes the ongoing vaccination rollout a truly daunting endeavor indeed. The fact that the administration of Covid-19 vaccinations through an Emergency Use Authorization is an undertaking that has never been attempted before in the civilian population gives us an opportunity to closely assess the gravity of the unprecedented challenge that lies ahead.

Can we try to peel away the layers to see exactly what it is that makes the world’s largest vaccination rollout so daunting and complex? What is it that defines the level of complexity of a situation? Can we perhaps conceptualize the type of response required for the challenges that many nations are currently grappling with?

To help answer the above questions, I will examine some of the most pressing challenges facing the vaccination rollout through the eyes of complexity. And to do that, we begin by taking a brief tour of the Cynefin framework.

Using the Cynefin framework to assess and respond to the complexity of the world around us
The Cynefin framework is a conceptual model that helps viewing and understanding a situation or a set of circumstances evolving around us. Often presented as a “sense-making device”, the Cynefin framework helps recognize a situation and subsequently determine the type of contextual response that may be best suited to address that specific situation or problem. From building national defense projects to establishing government strategies and policies, the Cynefin framework has been used across a vast array of organizations and contexts.

Essentially, the Cynefin framework perceives the situations and problems around us as belonging to one of four types: Simple/Obvious, Complicated, Complex, and Chaotic.


In the next section, I will present and discuss specific examples from the ongoing vaccination rollout that equate to the domains of the Cynefin framework. While a detailed discussion of the entire framework is worthy of a whole article by itself, let’s quickly do a counter clockwise on each of the domains. Starting with the ‘Obvious’ quadrant, this is where the realm of best practice standards and processes exists. As the name suggests, situations where the relationship between variables are clearly recorded and understood can be categorized as ‘Simple/Obvious’; causality is both linear as well as predictable. Further, there is no ambiguity here in terms of the exact solution or path that would need to be selected. Situations categorized as ‘Simple’ can be addressed using a Sense-Categorize-Respond pathway.

Moving on to the ‘Complicated’ quadrant, we now begin to see multiple potential solutions arise to the same problem. Solutions proposed might be considered good practice but are not necessarily unanimously agreed upon. In addition, while causality amongst the different variables might not be readily known, there is a good grasp of exactly what the unknowns are. Situations categorized as ‘Complicated’ can be addressed using a Sense-Analyze-Respond pathway.

As we move into the ‘Complex’ quadrant, the level of ambiguity and uncertainty facing us also starts to increase. The causality and relationships between the variables can be non-linear and unpredictable. In addition, we may not even understand the full scope of the unknowns inherent to the situation. As can be inferred, no solutions are readily available for ‘Complex’ problems. Instead, a fair amount of experimentation may be needed to devise a solution. Situations categorized as ‘Complex’ can be addressed using a Probe-Sense-Respond pathway.

We now come to the ‘Chaotic’ quadrant; extreme ambiguity, unpredictability, and complexity of problems is the order of the day. Time is of the essence here: chaotic problems call for a rapid response and temporary control of the situation. Essentially, the goal here is to immediately propose and find a solution as opposed to doing a deep dive root cause analysis and finding the most optimal solution. Intriguingly enough, emergence of novel solutions is often seen in such circumstances. Situations categorized as ‘Chaotic’ can be addressed using an Act-Sense-Respond pathway.

Finally, the void in the center of the diagram above is often labelled as ‘Disorder’. Essentially, this area encapsulates situations where conflict might be present in something as fundamental as even defining the situation and therefore cannot be contextualized into any of the other four categories.

An excellent overview of the Cynefin framework by Dave Snowden, one of the founding researchers of this concept, can be found here.

Through the looking glass: making sense of the complexities of the vaccination rollout
It is important to emphasize that the use of the term ‘quadrant’ and ‘category’ referred to in the previous section is, in and of itself, quite arbitrary. Many of the problems we face can be fluid in nature and, therefore, exist along a spectrum of complexity. The Cynefin framework itself might best be perceived as a spectrum; therefore, problems or situations that we choose to tackle can potentially exist on the borderline between each of the different domains. The problems we perceive can also often swing back and forth across the framework depending on the depth, breadth, context, and chronology of the issue we choose to face.

Therefore, using the above framework as the backdrop, let’s look at three different challenges that we collectively and globally face in the ongoing vaccination rollout:

  1. Adapting recommended vaccination schedules to quickly expand the vaccine’s reach

This, to me, has got to be one of the most intriguing challenges facing nations across the world. With the B-117 variant of SARS-CoV-2 already gaining a foothold in many regions across the world and with other variants potentially not too far behind, governments across the world are at a crossroads:

Do we continue vaccinating people as per the authorized schedules but potentially allow other SARS-CoV-2 variants to gain traction within the community? Or do we maximize the number of people being vaccinated as early as possible by potentially relaxing how closely the vaccine administration schedules follow the recommendations?

The British government has taken a definitive first step in answering the above question by announcing that the recommended interval between doses may be increased by a significant margin while also allowing for doses from different manufacturers to be used for the same person if needed. Other nations might also follow suit while they investigate the risks of stretching out the vaccination schedules.

However, let’s examine this dilemma from the perspective of complexity. It’s fairly clear that the situation we face is at least a ‘Complex’ problem, perhaps even bordering on ‘Chaotic’. As most authorities across the world have indicated, time is of the essence here. The new SARS-CoV-2 variants have either already made landfall on our shores or soon will be. We may not have enough data to analyze yet. We may not have enough time to wait for emerging patterns at a population level. Before things get worse, the ship has to be righted first. At least in Britain’s instance, it seems that the authorities might be following an Act-Sense-Respond pathway while they wait for additional data. Other parts of the world might be following a Probe-Sense-Respond pathway as they investigate and closely observe data coming in from vaccine manufacturers and other nations.

  1. Identifying high-risk groups and tracking vaccine beneficiaries to administer a second dose

This is yet another immense challenge facing most nations and health authorities. Questions regarding which groups or communities to include in each phase of the vaccination rollout pose an interesting dilemma. The dynamic and evolving nature of allocating and prioritizing specific populations based on data coming in from clinical trials can be expected to stress test each nation’s immunization delivery system. Further, based on new data coming in on the SARS-CoV-2 variants, governments are faced with balancing administering vaccines to the highest risk groups first against administering vaccines to as many people as possible.

The above policy-level issues notwithstanding, from an implementation perspective, some of the biggest challenges might stem from appropriately identifying, contacting, and following-up with many of the priority groups. The who, when, where, how and by whom are all extremely critical questions that add to the complexity of this particular challenge. A vast sea of unknowns exists in this realm, including the uncertain state of vaccination coverage for the uninsured as well as traditional Medicaid program beneficiaries. With the sheer number of unknowns facing us, I would put this challenge squarely in the ‘Complex’ quadrant, at least for most regions. New solutions may need to be experimented and assessed in order to understand what works best when engaging and vaccinating high-risk groups on a mass scale. Therefore, a Probe-Sense-Respond pathway might potentially best be suited to address this challenge.

  1. Addressing vaccine confidence: encouraging the general public and specific high-risk sub-populations to receive vaccination

Recent surveys have shown that vaccine confidence might be a significant barrier to a successful vaccination rollout. Misinformation campaigns, concerns regarding the importance and safety of vaccines, mistrust of existing healthcare and government institutions, and pre-existing low vaccination coverage for non-COVID vaccines, all point to critical dependencies that most governments and authorities can expect to face as they open up vaccine administration to the general public. One can expect this to be a long journey as we claw back the ongoing erosion of confidence in vaccines amongst certain specific sub-populations throughout the world. However, despite the above significant challenges to bolstering vaccine confidence, I would place this as a ‘Complicated’ issue primarily due to the wealth of evidence and recommended practices that already exist out there; providing accurate and contextual information, using media in a positive manner for public awareness campaigns, mobilizing cross-sector partnerships, and closely engaging healthcare providers are a few recommended solutions to encourage public confidence in vaccines.

Final thoughts
Ideally, groups of stakeholders from impacted organizations and communities would be involved in the above exercise – this would truly help unpack the various nuances and dependencies between parallel and intertwined processes, expectations, structures, and values. More importantly, the definition and scope of the problem itself determines where it ultimately falls within the spectrum of complexity. Each of the challenges described above can be further broken down into smaller parts, with each individual element encapsulating a different level of complexity. While the above analysis is by no means a comprehensive or exhaustive evaluation of the massive task of vaccinating the vast majority of earth’s population, it is meant to be a very preliminary exploration into perceiving complex situations and developing corresponding solutions.

For eleven long months, the pandemic has raged on viciously, both introducing as well as exposing complexities within our lives and systems. Humanity’s response by developing a highly efficacious vaccine has been swift and truly extraordinary. For now, it may be a race against time. But it’s also a race against our own existing structures, ideas, assumptions, certainties, fallibilities, and complexities. Let us hope that eleven months from now our collective response will have ended the horrors of the past eleven months.



Hiren Prabhakar has been in the healthcare sector for over 12 years, with a passionate focus on population health, public health, social determinants, health equity, and community resilience. He is currently a project manager, Enterprise Population Health, with Advocate Aurora Health, in Chicago.
With experience in both the US and Canadian healthcare systems, Hiren is a deep thinker on issues concerning integrating the population health and public health worlds. Hiren advises internal facilities and service lines on designing and optimizing population health strategies and initiatives. Hiren works with one of the largest ACOs in the nation and has helped deploy enterprise-wide strategies to equip providers to thrive in a value-based care environment. Hiren has a Masters in Population Health Management from the Bloomberg School of Public Health at Johns Hopkins University and a Masters in Health Administration from the Telfer School of Management at the University of Ottawa. The opinions expressed in this article do not reflect the opinions of Advocate Aurora Health.

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