COVID-19 has caused significant disruption worldwide and changed life as we know it. As the crisis deepens, opening up fault lines in the ways our economy, political structures, society and environment are connected, many change makers are also framing this as a clarion call for transforming the systems we all rely on - in other words, ‘systems change’. 

But what does it mean to translate the abstract idea of ‘systems change’ into more palpable and actionable things? How can we make ‘systems change’ more accessible to development practitioners at large? What qualifies as a ‘systemic problem’ when we talk about social change? 

At Forum for the Future (which we usually just call Forum), we have practised in the field of system change for almost 25 years, partnering with governments, civil society and business leaders to work towards a desired future together.

In this article, we will use the example of India’s health care system, to explore what systems change can look like in-practice. We do this with the caveat that systems are complex and it can be dangerous to generalise when they depend so heavily on context. 

Systems change is both the process of change and the outcome of that process. Donella Meadows, for example, informs us that ‘a change in purpose changes a system profoundly, even if every element and interconnection remains the same’. 

Changing the elements and the way they relate to each other also causes shifts in the workings of the system and can therefore be used to bring about desired changes. These can be understood as leverage points for systems change.

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At Forum, we often start with the following systemic practices or approaches (Image 1) that help us to reflect on how we are working systemically and the different leverage points one might have in catalysing systems change.

Each approach can give a practitioner a different aspect to any given system and exploration opportunities. They help us understand or diagnose a problem more closely - in a systemic way - that allows a practitioner to get to the roots of the challenges. This deeper level of understanding helps in generating ideas for spaces to intervene in a system.

We have focused on four approaches:

1. Enable the system to see itself, hold the whole picture
2. Work at different levels concurrently
3. Identify connections and how parts interact
4. Consider different timescales and consequences over time

1. Enable the system to see itself

Donella Meadows, a pioneer in systems thinking, defines a system as ‘an interconnected set of elements that is coherently organized in a way that achieves something.’ Based on this definition, any system consists of three key things – elements, interconnectedness, and a goal or purpose of the system. 

The elements and actors within a system very rarely have complete visibility and struggle to see the whole picture that they are a part of. Yet it can be a source of great insight. Systems thinkers usually use system mapping techniques such as mapping a system’s behaviour over time, the Iceberg model or causal loop diagrams (explored in the next section) to get this visibility. To start with, the exercise of mapping a system can be as simple as laying out the various elements, sub-systems and levels of a system on a piece of paper and connecting the nodes to understand the various interactions between them.

If we take the example of India’s Health system, it comprises various sub-systems and elements at the levels of government, market and civil society that interact with each other through relationships and flows of resources, information and more. A very simple map of this system can look like Image 2, listing out the various sub-systems, elements, and a broad level exchange between them. 

IMAGE 2

A system map can be made richer by understanding how various parts of a system interact, what are the patterns in those interactions and what is the nature of those patterns (e.g. do they balance some relationships in the system or do they reinforce some attributes of the system). 

A system is ‘an interconnected set of elements that is coherently organized in a way that achieves something.’

2. Identify connections and how parts interact

In this section we will use the example of connections and relationships between the key elements of the health system, to understand how COVID-19 has impacted India’s health system. We will work with the following two elements:

1. Human resources (in the form of health care workers at all levels, including doctors and front line workers) and,
2. Physical Infrastructure (including equipment, hospital beds, quarantine facilities).

A system’s properties are often emergent, i.e. properties that are a result of its various parts interacting with each other within the whole. Often these interactions are not explicit and a better understanding of flows and relationships can help identify leverage points in the system. 

A Causal Loop Diagram (CLD) helps identify feedback loops in a system which can be reinforcing or balancing and interact with each other and the system in complex ways. An example is illustrated in Image 3 where (+) sign on a causal link denotes that the elements change in the same direction (increase in one will cause an increase in the other and vice-versa) whereas (-) sign indicates the opposite (increase in one will cause a decrease in the other). In the example, an increased number of births lead to an increased population and an increased population leads to an increased number of births - thus making this a reinforcing loop. Whereas an increased number of deaths will lead to a decrease in population and an increased population will lead to more deaths, making this a balancing loop.

Image 3: https://kumu.io/hansikasingh/healthcare-system#indias-healthcare-system

Specifically for India’s healthcare system, the various attributes of two elements - Human resource and Infrastructure - are critical for the effectiveness of the Health system at large. Image 4 illustrates this clearly where the number of health workers have causal links with workload and eventually the effectiveness of the healthcare system, creating a balancing loop (B1).

Balancing loops bring the system to a desired state and help keep it there. In this case, fewer human resources will mean more workload and decreased motivation in the workforce, leading to decreased overall ineffectiveness in dealing with a crisis like COVID-19. Similarly, infrastructure helps build the capacity of the health system that eventually makes it more effective, instills confidence and enables investment in the system making a reinforcing loop (R1). Reinforcing loops act to compound changes in one direction. It is also evident from this CLD that investment in the health system over a period of time feeds into the two key elements of health workers and physical infrastructure, and will have a compounded effect on the overall ability of the health system to manage the pandemic.

Image 4: https://kumu.io/hansikasingh/healthcare-system#indias-healthcare-system

With a surge in the number of COVID-19 patients, the shortages of infrastructure and human resources are becoming more pronounced as hospitals run out of beds and doctors. Growing public investment in both these elements of the public health system will create positive feedback loops and that will lead to increased long term effectiveness.

3. Working at different levels concurrently

The casual relationships and shortages discussed above play out very differently at different levels of the health care system. For instance, in rural India, the system shortages are even more pronounced. In terms of access, most people in rural India may need to travel 10 kms on average to access a primary or community health facility - and some may arrive to find no one, because 60% of primary health centres (PHCs) in India have only one doctor while about five per cent have none [1].

As migrant workers displaced by the pandemic return home, contact tracing falls on the shoulders of the ASHA (Accredited Social Health Activist) workers who are already overburdened with other responsibilities - in many States, there are about nine ASHA workers for every 10,000 people.

This illustrates the need for systems thinkers to understand the challenges of the system at different levels and working at those levels with tailored approaches, instead of a ‘one-size fits all’ approach. We will explore in the next section, using a systems lens, why these shortages exist in the first place by understanding the behaviour of India’s health system over time.

4. Consider different timescales and consequence over time

Studying how a system evolves over time allows systems practitioners to identify and focus on patterns ofchange over time, rather than on isolated events. This can lead to richer discussions on how and why something is changing and those insights can help inform responses to the observed patterns. Donella Meadows highlights the importance of this approach, asserting that ‘…starting with the history [of a system] discourages the common and distracting tendency we all have to define a problem not by the system’s actual behaviour, but by the lack of our favourite solution.’

At Forum, we often use the Multi-Level Perspective (MLP), a prominent socio-technical transition framework, to understand the evolution of a system over time. The MLP suggests that transitions take place through a series of interaction processes within and among three analytical levels: niches, regimes and landscape (Image 5). The regime can be visualised as the mainstream and the way things get done today. The niche can be thought of as the space in which new and unstable technologies, ideas, concepts and innovations emerge until some mature into the mainstream. The landscape relates to the external context shaping the way the niche and regime interact.

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If we use this framework to draw a simple visualisation of evolution of India’s health care system we can observe many waves of transitions - sourced from Ms K Sujatha Rao’s book [2] on the India health system - as illustrated in Image 6.

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Examining the evolution of India’s health system sheds light on the following insights -

• The traditional health and medicine system dominant in pre-colonial India was written off as unscientific and irrational in the process of India’s colonisation. This led to the loss of knowledge, ways of seeing and ways of living that may have caused a shift in the goal of our health system, from living a healthy life to curing diseases.
  
  
• Public health was not a priority during colonial times, which were marked by very low spending on health and the rise of exclusive hospitals equipped with qualified doctors and nurses to serve the needs of privileged ‘enclaves.’
  
  
• Independent India also struggled to allocate resources to the health system and the trend of fiscal underinvestment continued. In the first three decades after independence, three key approaches shaped India’s health system
  • 1) A focus on combating infectious diseases and family planning organised the primary health system in a uniquely mission-focused way around these programmes ;
  • 2) A focus on teaching hospitals to address the shortage of trained staff; and;
  • 3) Weak prioritisation of limited resources that resulted in patchy and inadequate investment in primary healthcare.
    
    
• There have also been success stories like the Comprehensive Rural Health Project (CHRP, or popularly known as the Jamkhed Experiment or model) which pioneered community-based primary healthcare using rural health workers. The model has been recognised by UNICEF & WHO and has been introduced in over 100 countries across the world.
  
  
• India entered the new millennium with a severely compromised capacity to achieve its vision of health for all. The National Health Policy of 2002 proposed increasing public investment in health to 2% of India’s GDP. It is telling that even in 2019, this number was still 1.28% - whereas countries such as the USA and the UK spend about 18% and 10% of GDP respectively on healthcare.
  
  
• Because of inadequate financial support, capital expenditure in the healthcare system took an immediate hit, which translated into inadequate infrastructure.
  
  
• The rural healthcare system struggles with the hangover of working in a mission mode, in which success was measured in terms of eliminating diseases like smallpox.
  
  
• Over time, an increasing number of people started denying themselves timely healthcare due to their inability to pay or entered cycles of indebtedness due to high out-of-pocket expenditure on health. The NSSO’s household survey (60th round [3]) suggests over 20% people did not seek treatment despite their need, citing financial reasons. Other studies indicate that up to 40% of those hospitalised in India are indebted [4].
  
  
• These trends have resulted in a fragmented and market/NGO reliant health care system that comprises private hospitals concentrated in urban centers for those who can afford them, and the growing dependence on NGOs to address the neglected needs of the economically poor.

This kind of timeline analysis tells us that the shortages in India’s healthcare system have been a long time in the making, and the current COVID-19 crisis has put additional pressures on the system across existing fault lines. India is relying on measures like extended lockdowns to build temporary capacity around these shortfalls, and such measures can be effective in the short-term to provide some relief to a system in shock.

What’s next on the systems change journey?

Using systemic practices we can arrive at insights that help generate a set of questions for the next stage of the systems change journey - which will be to identify areas of intervention and to work collaboratively towards a shared vision. The insights gathered in the process of writing this article have led me to ask the following questions about India’s health system -

-   Is the health system currently aligned with its goals? (According to the WHO, healthcare systems' goals are good health for the citizens, responsiveness to the expectations of the population, and fair means of funding operations)

-   How might we use the lessons from COVID-19 to understand and act upon the gaps exposed in the health system?

-   How might we imagine the future of India’s healthcare as it emerges from this crisis, and work towards it collaboratively?

Through this example of India’s health system, hopefully some interesting reflections have emerged for development practitioners, to use a combination of systemic practices to demystify what ‘systemic’ challenges mean and how to understand them for informing systems change.

We hope that this helps to illustrate the centrality of systems thinking and systemic practices towards driving long-term and transformational change, rather than superficial change that reinforces the status-quo.

In subsequent articles of this series, we will continue to explore systemic practices using examples of other key systems whose workings and relationships have been revealed in more detail by the COVID-19 crisis.

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Note: A key systemic practice is engaging multiple perspectives. The following people were a key source of support and insight in  the writing of this article -

-   Yamini Srivastav, Charlie Thorneycroft, Anna Warrington & Louise Armstrong (Forum for the Future)

-   Dr. Radhika Kaulgud (Public-Health practitioner)

-   Saumyaa Naidu (Designer & Researcher)

Want to learn more about system change? See more at our School of System Change and learn about their programmes and resources.

You may also be interested in exploring Forum's latest Future of Sustainability report, titled "From System Shock to System Change - Time to Transform".

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[1] According to the Economic Survey 2018-19, tabled in the Parliament on July 4, 2019.

[2] Rao, K. Sujatha. Do We Care?: India’s Health System. Oxford University Press, 2016.

[3] The NSSO undertook this survey between January to June 2004

[4] David Peters, A. Yazbeck, R.Sharma et al., Better Health Systems for India’s poor: Findings, Analysis and Options (Washington, DC: World Bank, 2002)

Cover Image: Photo by Md Shafi Ahmad on Unsplash