How we built a health systems map

How does change happen, on a large scale and persist over a long time? How do we work on bringing about change and not be blindsided by its unintended consequences?

These were the questions we were confronted with, when we worked with an organization working on community health in India. We felt we needed to go beyond just the immediate problem being articulated by our client and understand the problem in its entirety. It was a complex and dynamic challenge.

Adopting the systemic approach, we understood root causes and underlying patterns dictating the health systems in the country, especially in resource poor states. This helped our client develop strategies that considered the system in its entirety and then work on aspects that provided more leverage for creating enduring social impact.

Typically, a systems mapping exercise has 4 phases

Systems Practice Journey Map, adapted from from Systems Practice Workbook by the Omidyar Group 

We worked on Phase 1 and Phase 2 of the system mapping exercise, which we elaborate in this article.

Phase 1: Understanding the system and aspirations for its change

Step A: Develop a Longer Term Vision and Nearer Term Desired Outcomes for the system

The first step was to identify the organisation’s area of focus. This was done by defining both a longer-term vision of how the system should behave and a nearer term desired outcomes. Both the longer term vision and nearer team desired outcomes were developed during a creative thinking workshop with the client team and its network partners.  

With two decades of work in communities, our client team was passionate about an effective, well-functioning system for community health. Their longer term vision for the system (guiding star) was defined as

“A public health system that is responsive to the (maternal and child) health needs of the communities and meets them effectively.”

The nearer term outcomes (near stars) that would take us closer to the longer term vision (guiding star) were articulated as

  • Empowering local communities, building people owned institutions that create ownership for their own maternal and child health needs. 
  • Strengthening public health systems by enhancing capabilities of functionaries across hierarchies for effective health service delivery.
  • Developing a sustainable model of funding to create and implement an effective strategy to improve the public health systems catering to maternal and child health needs.

Step B: Develop a Framing Question

Having understood the aspirations of the team through various in person and workshop discussions, we felt a need for looking at the public health system (focus on maternal & child health) with a holistic lens. The aim was to understand why the various elements of the health system behave as they do currently and keep the system behaving as it does.

We developed a framing question that would direct our enquiry into the system about the elements that need to be analyzed and affected. The question was:

“What forces account for the current maternal and child health status in our local communities?”

Step C: Explore Forces and Create Themes

We sought to answer this question by deeply listening to all stakeholders, understanding where they are, how they participate in the system and how they interact with each other. We had in-depth conversations with community members, community workers, government functionaries, representatives of various organizations working on community health and the CORE secretariat team. This was followed by a creative brainstorming workshop to deep dive into the aspirations and challenges of the client and its network. These insights and a thorough secondary study helped us understand the macro and micro forces impacting the maternal and child health in the communities.

The in-depth conversation, creative deep dive workshop and the secondary study unfolded the multiple forces acting in the system. An analysis of these forces and their interconnections (systems map) has provided some hypotheses on why the public health system behaves as it does. These forces include people, trends, events, norms, beliefs, phenomena, institutions, laws and policies etc., that could enable or inhibit maternal and child health in our communities.

Illustration of few themes and forces dictating the current behaviour of health system in India

Step D: Analyze Causes and Effects

We discovered a few key themes – clusters of related forces, that dictated the behaviour of the public health system in our local communities. These themes allowed us to go deeper into the behavior of the system by analyzing the causes and effects of each of the key themes. The causes and effects, or factors, were analysed holistically and rigorously – by listing all structural, attitudinal and transactional factors. 

  • Structural factors are derived from an understanding of physical and social environment in which communities live – natural and built environment, political, social, economic institutions and infrastructure. 
  • Attitudinal factors refer to beliefs, values, norms and intergroup relations that affect how large groups of people think and behave. 
  • Transactional factors are processes used by and interactions among key people as they deal with important social, political, and economic issues.
Theme: Lack of Trained Personnel – Illustration of its causes and effects

Step E: Create Loops

The previous steps set the basis for drawing out underlying patterns that exist in keeping the public health system in its current state. These entrenched patterns were critical to uncover, as large-scale change in the public health system will only happen when these patterns are changed – in effect they provide the potential for change in our system. We attempted to understand these patterns by identifying the important factors from the previous step and enquiring into the effects of the factor. When the effects circled back to cause the factor we started with, we uncovered a causal loop – a pattern in the public health system. These causal loops are named to reflect their place in the system.

Step F: Discover the Deep Structure

After creating several causal loops, we stepped back and saw that there were some important and repeating elements and relationships – for instance, lack of awareness of public rights & entitlements seemed to be part of multiple loops that were driving the system behaviour. These elements together appeared to be the crux of the system. 

This dominant behavior, also called the deep structure of the system, holds the centre of the systems map. The different regions of the systems map are connected with the factors in the deep structure of the system. The deep structure, regions and the various causal loops with all the interconnections gives us the system map and a narrative to explain the current conditions of the system.

The Deep Structure of Indian Public Health System

Step G: Build, Socialise and Iterate the System Map

This systems map is a living document that will evolve with feedback and further engagement with the system over time. It is important to iterate and socialize the system map with experts and interested stakeholders in the field – partners, donors and other civil society organizations. 

Phase 2: Finding points of leverage to create enduring change in the system

Step A: Develop a Systemic Problem Statement

Mapping the system enabled visualizing the current public health system in such a way that it allowed us to identify opportunities for creating enduring impact. The key insight from the system mapping exercise was that there is a vicious loop operating between communities’ lack of awareness of what they need and can avail from the public health system and government’s lack of focus in improving the public system. The resultant poor infrastructure and public health services failure was moving healthcare disproportionately to the private sector. This exacerbated communities’ lack of awareness of what they need and can avail from the public health system and so the vicious cycle continued, deteriorating the public health system further and thus negatively impacting the maternal and child health status of our communities. 

The mapping exercise brought our attention to what we dislike about the current public system and identify ways to shift the system to a healthier state. This insight about the deep structure and complete systems map gives us the opportunity to identify leverages in the system – the places where small effort creates large impact.  The enquiry into leverages began by defining, at first, a problem statement for the system.

Problem Statement

To define the problem statement, we asked ourselves a series of questions about the behaviour of the current system and arrived at the following insights 

  • The current system serves to keep the vulnerable communities, marginalized sections from availing quality health services and furthers their vulnerability.
  •  The dominant, even if undesired purpose of the system is to push people to unaffordable healthcare. 
  • The current system is optimized to deliver poor quality health services to local communities.

These insights helped us arrive the current dominant behaviours of the system. This when juxtaposed with our Guiding and Near Stars, gave us the Problem Statement. This statement defines the shift that we desire for the public health system.

“We are trying to move from a system that perpetuates poor health in local communities, to a system that holistically and effectively responds to health needs (especially maternal and child) of the communities.”

Step B: Find Opportunities for Leverage

We then looked at the systems map to identify leverage opportunities – these could have varying potential for impact. Our search was for areas that were deeply entrenched and impacted the system adversely. These factors were unlikely to suddenly change in the near future – for instance, Quality of PHS or Poor Status of Women. We also searched for areas where positive change is already happening – for instance, High Networth Individuals (HNI) focus on MNCH initiatives and appetite for trials & experiments. Then there were areas that had potential to affect many more factors in the long run – for instance, Education of Girls.

The points of leverage for improving the Public Health System

Multiple key areas and leverages have been illuminated by the systems map. The client could prioritise these to craft a coherent strategy for the future for a system wide impact. One of the key strategic levers or point of entry appeared to be in shifting ‘Lack of Community/ Public Action’ towards a virtuous cycle. This involved collectivizing local community members to articulate their needs, increase their awareness of rights & entitlements, increase community ownership of their health needs – leading to increased priority on health. This, we believed, would have a positive impact on investments and collaborations in the Public Health System.

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