What do we mean when we talk about systems change? Is it just an NGO buzzword or does it offer something new to help solve society’s most complex challenges? How can we apply systems thinking approaches to problems we care about?
My DrPH DELTA project seeks to address these questions by applying a systems thinking lens to the problem of neglected tropical diseases (NTDs).
The NTD System
The term NTDs encompasses 20 diseases – primarily bacterial and parasitic infections – found most often in tropical and sub-tropical environments. NTDs affect over 1.5 billion people worldwide and are the cause of death for approximately 300,000 annually. NTDs are both a cause and effect of poverty. While there is a particularly heavy burden in low-income countries in sub-Saharan Africa, at least half of the world’s NTDs occur among the poor living in higher-income countries.
Five of the NTDs – lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminths, and trachoma – can be effectively controlled and potentially even eliminated through the use of preventive medicines (known as preventive chemotherapy) administered by mass drug administration (MDA). A number of public-private partnerships have been formed through which major pharmaceutical companies have donated billions of dollars’ worth of free preventive chemotherapy drugs that are then distributed to at-risk communities through MDA by networks of governmental and nongovernmental partners. NTDs have generated an increasing amount of attention from aid agencies and philanthropists over the past decade because NTDs are widely seen as one of the best investments in global health. Thanks in large part to the availability of donated medicines, effective preventive chemotherapy is estimated to cost less than US$0.50 per person per year in many circumstances. In 2013, the World Health Assembly agreed to an ambitious set of goals (aka “the end goals”) to control or eliminate NTDs by 2020.
NTDs are a complex problem
In a sense, NTDs appear to represent a straightforward problem. We generally understand the epidemiology of the diseases and have developed evidence-based, low-cost methods for treating them. The NTD community has been very successful in scaling up MDA programs; in 2017 alone, over 1 billion preventive chemotherapy treatments were administered to people at risk. It may seem that the only thing lacking to rid the world of these diseases forever is more funding to continue scaling up what we know works.
The reality is that, despite these successes, there are many reasons NTDs also fit the criteria of what some might call a “complex problem,” or one that can’t be solved solely through implementing known solutions, but that requires learning on behalf of many stakeholders in order to make progress.
It is becoming increasingly clear that the complexities involved in ending NTDs will prevent most countries from achieving the 2020 end goals. Even though the needed drugs have been donated, their supply is currently greater than the capacity to deliver them in many countries. Addressing this need will require an estimated $200 million in additional funding annually, but it will also require enormous efforts to build local health worker capacity, and build more sustainable NTD programs. There is a long-running debate in global health, and particularly in the NTD community, regarding the proper balance between vertical, disease-specific approaches (such as many MDA campaigns) and more horizontal approaches that build on existing health systems. Different experts have divergent opinions about whether vertical MDA campaigns strengthen or impede the development of local health systems. Among many other examples of complexity within the NTD sector is the fact that the many NTD partnerships contain large numbers of interconnected relationships with non-linear interactions.
Complex problems require systems thinking
The systems thinking iceberg (Figure 1) is a tool that illustrates one approach to thinking systemically about complex problems, such as NTDs. In this diagram, the iceberg represents the entirety of a complex problem, some of which is visible above the surface but the majority of which is out of sight below the surface. It is natural and common for us to attempt to solve complex problems by reacting to the events and trends that are easily apparent. However, failing to change the systems structure – or the interdependent relationships among the pressures, policies, power dynamics, perceptions, etc. that drive the above-the-surface system behavior – limits our ability to solve the problem and often results in unintended consequences that can make the problem worse than it was to begin with.
Figure 1 – Systems Thinking Iceberg (Stroh, 2016)
Systems change focuses on transformational changes in the systemic structure or this “below-the-surface” portion of the iceberg. Because root causes of complex problems touch the work of many stakeholders, systems change requires engaging multiple stakeholder groups with different perspectives to generate a holistic understanding of the system's structure. This systemic convening must be accompanied by an increased capacity for thinking systemically about the complexities of a problem.
My DELTA project host organization, the END Fund, is an innovative private philanthropic initiative working to end the five preventive chemotherapy NTDs. The END Fund seeks to take a system-wide approach that focuses on understanding the NTD space – its players, needs, gaps, and points of leverage – and mobilizing and directing resources to the places where small investments can yield outsized returns. My project is using qualitative and quantitative research to engage NTD stakeholders in a process to try to gain a deeper understanding of the complexities in the NTD system structure in order to identify leverage points for systems change. Achieving the ambitious targets for ending NTDs may depend on the NTD community’s ability to work together to think systemically about the complex challenges they collectively face.