What we mean by 'system change'

Apr 6, 2022

Leading effective system change starts by defining what we mean when we say, “system change.”

Mid-Iowa Health Foundation’s journey in offering the HealthConnect Fellowship has highlighted the importance of having shared understanding of terms we use to guide our work. Because the Fellowship aims to support advocates in leading system changes, we have found it especially valuable to spend time discussing the term.

A working definition we’ve started to use is the following:

“System change is impacting the actors whose decisions will create community-wide change.”

Within this definition, however, are important considerations. Here are insights from conversations among Mid-Iowa Health Foundation staff, mentors, and fellows:

1. What do we mean by a “system”?

Fellow Malai Amfahr with the Campaign for Grade-Level Reading views system change as, “impacting the various interconnected parts of a unified whole (a system) in some way toward a shared purpose.”

To achieve that purpose, we must first consider whether the various parts add up to a system that when changed will have the impact we intend. In this blog, Lead Mentor Rick Kozin explores the essential elements that make up a system by looking at the pandemic response in the United States. According to Kozin:

The essentials of a system are in place when “the system” can effectively reach (jurisdiction and credibility) the desired population, is competent to provide what is needed, and has the capacity (authority and resources) to make it happen.

Amfahr also encourages us to think about how various systems overlap and influence each other. For example, what are the ways in which health care systems influence education and how do housing systems influence health care. Recognizing these connections can help us identify which system to target.

2. Why do systems exist in the first place?

Fellow Dawn Martinez Oropeza with Al Éxito says we need to understand how the system we’re targeting is built and will the changes we aim to make go deep enough.

“Systems are structures that have been in place since before the invasion of this country to empower those with money and resources, which perpetuate that power,” she says. “So changes need to happen in dismantling that and creating a new inclusive model.”

3. What is the scope of impact an intended change will make?

“Not all change needs to happen at the top of the system and not all change that happens at the top is systems change,” says Kozin.

To Kozin’s point, system change doesn’t happen just by engaging leaders who are making decisions at the top level of a system. Those decisions may not have a broad impact on people who engage with the system.

“System change has to be defined as population-based change (not individual) and with long-term outcomes,” says Fellow Erin Drinnin with United Way of Central Iowa.

This means identifying the right decision-makers within a system whose decisions would ultimately impact many people. Or, another way to think about it, which levers can you adjust within a system that will have a ripple effect across the system that will, in turn, make a difference for those who engage with the system.  

4. What change are we after?

To define “system change” also means defining what we want to see changed. Mid-Iowa Health Foundation is focused on addressing the social determinants of health to improve the overall health and well-being of central Iowans.

Effectively addressing the social determinants of health requires approaching the work with a health equity lens, which recognizes that some individuals are more impacted by challenges that influence their health and well-being. According to Dr. Nalo Johnson, President and CEO of the Foundation, health equity is about “supporting opportunities for everyone to live the healthiest life possible through the reduction of barriers in social, economic, and environmental conditions that impact health.”

Fellows agree that the work must involve removing barriers and supporting individuals disproportionally impacted. “System change is removing those barriers that cause people to, in my specific work, be homeless,” said Fellow Angie Arthur with Homeward. “What are those barriers that people encounter within the system that make it more difficult for them to achieve their goals and where are those things that should be present in the system that could help people.”

Listening to and partnering with those disproportionately impacted, who have direct experience with the system(s), is a critical part of identifying what change to pursue.

5. Where do we target our efforts?

Entities – governments, businesses, and organizations – are not the ones making decisions; it’s people within those entities who are creating the systems and policies that have a broad impact. By defining the change(s) we want to make and which system(s) to target, we can then think critically about who can make decisions that would lead to the outcomes we want to see.

People focus on creating structure and processes as part of their jobs within a system, says Martinez Oropeza. System change requires being reflective of our own practices and the structures we’re creating and upholding that are keeping problems in place, as we work to influence others to make changes.

6. Are we prepared to take on systems-change work?

According to FSG’s The Water of Systems Change, the work is about “shifting the conditions that hold a problem in place.” This means going deeper than structural changes to policies, practices, and resource flows. The deeper work involves building relationships, altering power dynamics, and adjusting mental models that then shape the policies and practices. This kind of work is often harder and takes longer to achieve, but it’s the kind of effort that leads to long-term transformational change.

Tools for working on system change:

The following resources have been helpful for fellows to think about system change and how to be proactive in this work:  

• The Waters Center also offers habits of a system thinker that explain how advocates approach system change in their daily work.

• Community Catalyst System of Advocacy outlines the six capacities for effective system change.

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