A Systems Leadership Approach to Systems Change In Complex Environments: Eye Health in Bangladesh Case Study

Abstract

Sustainable and equitable population health improvement is a goal not all public health approaches can deliver on. Public health outcomes emerge from multiple unpredictable, dynamic, adaptive, and interconnected factors. There is a growing demand for public health interventions that align with the unique characteristics of complex systems rather than applying methods rooted in the linear cause-and-effect relationships of clinical interventions (Rutter et al., 2017). The danger of the continued use of reductionist approaches to address complex public health issues is sustained poor health outcomes and the perpetuation of inequitable system functioning (Kania et al., 2018). This paper contributes to the growing field of complex systems-informed practice in public health and the operationalization of systems leadership as a practice approach. First, the foundational concepts for this initiative are presented, including complex adaptive systems, systems thinking, and systems leadership. This project then examined the application of these concepts during the early stages of a large-scale systems change initiative to improve eye health in Bangladesh. An action research case study methodology was employed to reflectively examine the early efforts to define the critical intervention points, communicate higher-level systems concepts across cultures, sectors, and practitioners, iteratively adjust the approach, and engage non-traditional stakeholders. Multiple data sources contributed to the development of the case study, including 25 semi-structured qualitative interviews with Sylhet and Dhaka practitioners engaged in this initiative through local workshops. The data was analyzed and organized to advance our understanding of the systems leadership approach in this context. The results from this project stage summarize several learning points, including the importance of early emphasis on communicating the concepts across all involved partners and redefining knowledge to include context expertise about local system dynamics from regional leaders. Two significant practice shifts related to this approach are centering the beneficiary’s experience to drive solution generation and reliably capturing learning and insight as an intentional outcome that must be disseminated and fed back into planning. Lastly, an adapted action research framework is proposed to guide an iterative, collaborative, and reflective approach to systems thinking and systems leadership in complex public health environments.