The efficiency trap: Wicked problems, complexity, and adaptive governance in health systems policy

Health systems in many high-income countries are now operating in conditions where clinical, social, and system complexity are the norm rather than the exception. Yet dominant policy frameworks continue to prioritise efficiency, throughput, and narrowly defined performance metrics, reflecting assumptions better suited to linear and episodic models of care. While efficiency seeks to maximise outputs from finite resources, it often operates in tension with equity, which requires resources to be distributed according to need. This Policy Comment introduces the concept of the efficiency trap to describe a structural governance failure in which efficiency-dominated funding and accountability regimes systematically misalign with the realities of complex care. Using hospital settings as a diagnostic lens, the paper argues that many contemporary pressures-such as delayed discharges, workforce strain, and inequitable outcomes-are predictable consequences of policy design rather than failures of implementation. While grounded in health systems, the analysis highlights a governance challenge relevant across multiple countries reliant on activity-based funding and performance targets. The paper concludes by outlining implications for health system governance, calling for accountability frameworks that better recognise interdependence, coordination, and adaptive capacity in complex care environments.