Aptive Insights: Understanding Systems Change in Public Health

Understanding Systems Change in Public Health



What is systems change? What does this look like in public health? How do we make change at the systems level? Dr. Kelly Sanders, a health transformation expert at Aptive, sits down with Dr. Christina Welter to discuss leading systems change in public health and dives into problem definition, how to make change, approaching stakeholder buy-in and sustaining intentionally made changes.

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What is systems change?

Systems change is a process of helping ourselves realize our own assumptions about how we look at the world. It’s a process of building intimate, challenging, yet trusting relationships, and we need those relationships to work collaboratively. By working together, we ultimately see different perspectives, different opportunities and different leverage points to understand the root causes of today’s most complex problems and then work together to find pathways that create innovation. And that can impact the system in a way that maybe we never thought about before. So systems change is really something that is iterative, it happens over time and it’s about yourself: it’s about how you work with others and it’s how you work with your organization or your community to identify opportunities for sustainable change.

Why do we need systems change and why do we need it now?

Systems change is needed now because we desperately need to be impacting equity and addressing racial health and social and economic justice. Profound health disparities persist and have worsened due to health inequities that remain despite decades of evidence demonstrating the need to focus on health equity and more ‘upstream’ structural and social determinants of health.[i] So we see evidence after evidence after evidence that addressing public health from the tip of the iceberg, from the technical perspective, is not working. Now is the time, more than ever, as we see these tremendous, terrible health disparities due to health inequities, to really transform the system.

How do we achieve change at the systems level?

First, it takes commitment, it takes passion, it takes perseverance. These are not quick, short approaches or fixes. If you aren’t interested in the long game, then systems change probably isn’t for you.

At the simplest level, one of my favorite exercises is just to go talk to different sectors and people outside the world I live in and start to ask, “How do you perceive this particular situation? How are you experiencing this challenge or this problem? What do you know that works about it or what are you doing about it? What resources do you have? What don’t you have? What would you want to see?” And by talking to other people with different perspectives, I start to see connections that show where I’m different or similar and then I can put these folks together in unique ways to help address the problem or the opportunity.

The levels of systems change are not linear and they’re not black and white and straightforward. You’re working at all levels at once. We use environmental scans to get ourselves started with a lot of this work and we use systems thinking tools. The Five Whys is a very simple tool in terms of asking why five times to get yourself deeper and deeper into the root cause of the challenge. You can use different modeling perspectives to help see the different connection points. We do something called a rich picture, where you draw the different pieces of the system that are contributing to the problem. There are a variety of tools that we share in the book.

How do you deal with individuals who may not buy into the need for systems change?

If you go too fast with too many moving pieces, you will undoubtedly struggle with implementation. Change leadership is key. You have to pace the thinking, pace the dialogue and then pace the solutioning in a way that people have really bought into. But what’s important to me about that is also shared vision: creating a destination postcard, these benchmarks, these steps to celebrate along the way, to stop and reflect and learn. Is that going to for sure help you along the way? No, but it is what the evidence and experience tell us at least helps keep people more aligned and focused in a common direction.

What are your thoughts on leading systems change in environments where there are frequent shifts in power and leadership?

It’s really a behavior change, it’s a mindset change, it’s a culture shift. If you have a learning organization that helps foster that thinking and those diverse perspectives, you are more intuitively likely to see them practice systems change. So regardless of some of the changes in the leadership, the hierarchical leadership anyway, you’ll have practices in place that can help with sustained learnings, that kind of adaptive thinking, the leadership thinking.

I will also say strategic thinking goes along with systems thinking. And so through strategic and systems thinking — knowing different pressure points of organizations and ways in which to use our work with constituents and with partners and with community folks in a collaborative way — to help really define the organization’s role in that strategic way can also be very enduring, regardless of the administration.

Is it fair to say that when efforts at systems change have fallen short in the past it’s largely because we don’t understand the root issue and we didn’t get all the voices in the room to understand — and truly get the information we needed to understand — what was actually going on?

I want to be careful in terms of diagnosing what in the past has caused or continued some of the disparities or inequities and or inability to address a problem sufficiently because I know how hard our workforce works and they’ve been through so much. They’re truly passionate and committed to their jobs and are mission driven. This is not about any one person or any discipline or any training that isn’t effective — it’s about what else can and should we be doing. And I will say I think what’s missing is embracing a different way. Instead of having the answers all the time, can we stop and ask some questions about what we are even talking about here. Is this really the problem or situation? Do we understand it? Do we have all the right people at the table? Whose perspective are we favoring and why? Who isn’t at the table? Who needs to be at the table?

So it’s starting to open up and really think about some of those questions and then gaining additional skills to help facilitate and dialogue and bring in different data points that might really help us see something differently. And I want to be generative and positive and say I think there’s opportunity; it’s not to say the old way doesn’t have its benefits.

How do you sustain the systems changes you’ve achieved?

It’s about building a community and co-developing — and then reiterating how those values and norms and practices live out in every part of the program or organization, wherever you are. It’s about every time we can find an opportunity to live out those values, no matter how small or how robust.  Systems change also leads to sustainable impact because we are changing culture. We change culture through transformative, collective learning.

The other thing I would say is communications. You can never communicate enough. I think everybody says this, but we have realized the need to communicate and over communicate. It’s about creating all these structures where similar information is being shared and digested so that it’s consistent and regular — and then creating stopping points to reflect on what we just did, what worked, what didn’t. So sustainability and sustainment are a culture. It’s about creating a culture across the board, not just coming from the leader, but where we all are leaders and all can practice and support the — what we like to call an enabling environment — so the decisions are made more readily and easily by all that are a good reflection of our community.

Christina R. Welter, DrPH, MPH is the director of the Doctorate in Public Health Leadership Program and a clinical assistant professor in the Division of Health Policy and Administration at the University of Illinois at Chicago (UIC) School of Public Health.



[i]  Hummer, R. A. (2023). Race and Ethnicity, Racism, and Population Health in the United States: The Straightforward, the Complex, Innovations, and the Future. Demography, 60(3), 633–657.https://www.jstor.org/stable/48728438

Aptive Insights: Rethinking and Reinforcing the Health Care Supply Chain

Episode One

The COVID-19 pandemic highlighted the importance and deficiencies of the health care supply chain, which had a major impact on hospitals, pharmacies, health care providers and patients. Aptive’s Chief Health Care Officer, Jason Ormsby, sat down with Dr. Eugene Schneller, a national supply chain expert, to talk about what we learned from the pandemic, what changes are needed and what the future holds for health care supply chain management.

Read the summary, listen, or watch it here.