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23
Thu, May

Which Systems Change Should You Work On?

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More and more organizations are trying to influence the systems that are responsible for social problems. Developing impact strategies for system change can be challenging, though. In fact, one of the first questions in that process turns out to be one of the hardest: which system do we want to change, and in exactly which way?

Ashoka Globalizer is an accelerator program that helps advanced social entrepreneurs from around the world develop strategies for systems change. Many of these entrepreneurs have decades of experience with the systems that they work in. Even in these cases, it often takes several weeks to identify the specific systemic levers that we want to focus on with our strategies. By sharing the thought process of some of these social entrepreneurs, we hope to help other organizations identify the right system change goals for them.

We ask four questions to evaluate candidates for system change goals, in increasing order of priority:

  • How costly is it to achieve this goal (time and effort needed, and risks involved)?
  • How beneficial is this goal (improved health and outcomes of the system)?
  • To what extent can we use the unique strengths and assets of our venture to promote this goal?
  • Does the goal align with our values and motivation?

Given that we are dealing with complex, adaptive systems, trying to quantify the cost/benefit ratio of system changes is a fool's errand. Still, there are ways to get at least a rough sense of how different candidates compare. For example, a superficial change in a low-level system that is blocked by a dogmatic debate] is less attractive than [fairly deep change on a national level that might be achieved with a swift campaign.

A rough sense is also sufficient when it comes to the organization's strengths. The actual strategy is still to be defined, so it's hard to say exactly how relevant specific skills or relationships will be. We like strategies that allow social ventures to better leverage existing strengths for a particular systems change with only manageable adjustments to their current approach. That doesn't mean that we shy away from developing new skills, knowledge, and relationships. We just might not want to focus on a policy change as a systems change goal, if the venture has no advocacy skills, no relationships to decision makers, and no credibility when it comes to conducting studies and making policy recommendations.

Finally, and most important, we look at the values of the social venture and the personal motivations of the team members. This might seem counterintuitive, and it took us a while to realize this. The reason is simple, though: it's astounding what small social ventures can do if their approach is aligned with their values and motivations, and it's similarly astounding how little progress is achieved when there is a mismatch. Fortunately, most social entrepreneurs are aware of this and will reject any potential system change goal that might make sense on paper but does not resonate with them on a personal level.

Let's take a look at an example to see how these criteria play out in practice.

Meditech, founded by Dr. Rubiano, is improving the emergency and trauma care systems in the Andean region. Trauma care is a critical part of health systems. Colombia, for example, has 300,000 victims per year of severe trauma and a mortality rate of 50 percent. Andrés suggests that an effective trauma care system could reduce the mortality rate to 30 percent, which would save 60,000 people per year in Colombia alone.

During the strategy process, we considered three candidates for intended system changes. The first was better protocols for different steps of the trauma care paths in the Andean region, like recommended first aid procedures and initial checkup routines when patients arrive at hospitals. In systems terms, this would be a change in the rules and norms that regulate behavior, as well as better flows of information. This option got high ratings for all four criteria and soon emerged as a favorite:

  • Cost/benefit: good protocols have been shown to reduce error rates and improve health outcomes significantly in many fields, including trauma care. Copying protocols from Europe or the U.S. would not work, because health systems in the Andean region often lack the infrastructure and the medical equipment that these protocols require. Still, because of these examples, many stakeholders already believe in the value of protocols, and there would already be data to build upon. Better protocols can also lead to improvements quickly, and these improvements are easy to measure. Andrés and his team are confident that these data and success stories can be used to create traction and accelerate adoption without having to intervene at many institutions directly.
  • Unique strengths: Meditech has the experience, credibility, and connections to advance that goal. The organization helped create several other intermediaries and was even called the "founder of the emergency care system." Founded in 2001, Meditech also has a strong track-record of conducting scientific studies, as well as experience with developing protocols.
  • Values and motivation: Andrés and his team love the idea of protocols. Meditech's values include being scientific and driven by evidence, and the team wants to work with partners on an ecosystem level.

The second candidate for a systems change goal was to use the time and emotional support of patients' friends, families, and communities to ensure better rehabilitation after patients are released from hospitals. In systems terms, this would unlock a new resource to the system and allow new types of actors to assume the role of caregivers. The team quickly discarded this candidate based on a simple insight: improvements early on in the trauma care path have much more effect on health outcomes compared to improvements later on. Compared to better protocols, the benefits of this systems change would be low. Since there was also no obvious way to achieve this goal much more cheaply than the protocols, it just couldn't compete in terms of costs and benefits.

The third candidate was to turn firefighters into better first responders for trauma incidents. The team first discarded this goal based on a quick cost/benefit analysis: in contrast to hospitals, reaching firefighters would involve a grassroots approach, and even if this effort was successful, it would only cover a small part of the pre-hospital segment of the trauma care paths. This decision didn't feel right for the team, though. They had been working with firefighters for many years. The connection is so close that Andrés was named an honorary member of a national firefighter association for his contributions. The team particularly admired voluntary firefighters, as they have a genuine motivation to save lives, often without getting any compensation. Since Meditech was in a unique position to work with firefighters, and because this aspect of their work was important for the team on a personal level, we decided to include it in the strategy after all. We then realized that there are strong synergies between the goal to turn firefighters into better first responders and the goal to improve medical protocols: by working with firefighters, Meditech might be able to improve issues in the hand-over stage from pre-hospital to hospital care that also applies to other groups like ambulances. Also, the strategy for improved protocols would involve researchers, training institutions, NGOs, and many other stakeholders. Many of these partners work in the pre-hospital part of the trauma care path, so the existing relationships to firefighters might get pilot projects and local networks started more quickly. Finally, in the context of these pilots, firefighters would secure buy-in from local communities. This is because firefighters are respected members of these communities, and because the changes in procedures are very tangible and produce better outcomes quickly.

Conclusion

Many of the social entrepreneurs that we work with have decades of experience. Even in these cases, it often takes several weeks to identify the system change that we want to focus on. It's worth it, though: a clear system change goal allows for a robust impact strategy and often leads to a greater sense of focus and purpose in itself. In order to have that effect, potential system change goals should be evaluated not only in terms of costs and benefits, but also in terms of the venture's unique strengths and the team's values and motivations. 

We hope that these four criteria will help you find the right system change goal for your team as well!

Notice that all three candidates for Meditech's intended system change are very specific -- better protocols, a new resource, and an extended role --, and refer to very specific sub-systems -- the trauma care paths in the Andean region. In another article [https://ssir.org/articles/entry/systems_changebig_or_small], I discuss the advantages of these "Targeted System Changes". In "Mastering System Change" [https://ssir.org/articles/entry/mastering_system_change], Seelos and Mair discuss one advantage of this approach in more detail: by focusing on relatively small changes in specific sub-systems, there is less risk of doing harm, and more opportunities to learn and adjust one's approach as needed.]