Healthier Cities through Systems Thinking: Practical Considerations for City Leaders

Strengthening healthcare providers' leadership capabilities, interprofessional collaboration, and systems thinking: a conceptualization of the Clinical Scholars program impact

BACKGROUND

Healthcare provider leadership programs represent an intervention opportunity to support advancement of the national system of care and an evaluation of their program impacts is needed. Between 2016 and 2023, the Robert Wood Johnson Foundation (RWJF) funded Clinical Scholars (CS), a three-year equity-centered leadership training program for US healthcare providers. CS recruited participants (referred to as Fellows) in cohorts and engaged them as members of interprofessional teams to transform their careers and the health of their communities. The aim of this study was to evaluate Fellows' perspectives on the success of CS, specifically the program elements and their importance for community well-being and sustainability.

METHODS

We used the mixed methods group concept mapping (GCM) approach to evaluate Fellows' perspectives on program success. First, we conducted the qualitative phases of brainstorming, sorting, and rating with Fellows. Secondly, we conducted the quantitative phases using multi-dimensional scaling and hierarchical cluster analysis and integrated the sorting and rating information from each Fellow to develop a series of concept maps. Finally, we conducted the interpretation phase to synthesize findings. Fellows (N = 177) across five cohorts were invited to participate in the study.

RESULTS

Fifty-seven Fellows (32%) completed one or more GCM phases. A conceptual map emerged, consisting of seven thematic clusters, which showed that program value could be attributed to the following elements: "Resources", "Wicked Problem Impact Project (WPIP) Support", "Curriculum", "Thinking Bigger", "Leadership Training", "Networking", and "Teamwork." The pattern match showed that all seven clusters were highly rated by Fellows across the Community Well-being Impact and Sustainability domains.

CONCLUSION

Study findings support the value of the RWJF-CS program strategy of long-term investment in the development of healthcare leaders with applied skills in interprofessional collaboration who will be prepared to continue addressing complex, multi-faceted challenges in the system of care.

Complex Interventions for a Complex System? Using Systems Thinking to Explore Ways to Address Unhealthy Commodity Industry Influence on Public Health Policy

BACKGROUND

Interventions are needed to prevent and mitigate unhealthy commodity industry (UCI) influence on public health policy. Whilst literature on interventions is emerging, current conceptualisations remain incomplete as they lack considerations of the wider systemic complexities surrounding UCI influence, which may limit intervention effectiveness. This study applies systems thinking as a theoretical lens to help identify and explore how possible interventions relate to one another in the systems in which they are embedded. Related challenges to addressing UCI influence on policy, and actions to support interventions, were also explored.

METHODS

Online participatory workshops were conducted with stakeholders with expertise in UCIs. A systems map, depicting five pathways to UCI influence, and the Action Scales Model were used to help participants identify interventions and guide discussions. Codebook thematic analysis was used to analyse the data.

RESULTS

Fifty-two stakeholders participated in 23 workshops. Participants identified 27 diverse, interconnected and interdependent interventions corresponding to the systems map's pathways that reduce the ability of UCIs to influence policy. These include, for example, reform policy financing; regulate public-private partnerships (PPPs); reform science governance and funding; frame and reframe the narrative, challenge neoliberalism and gross domestic product (GDP) growth; leverage human rights; change practices on multistakeholder governance; and reform policy consultation and deliberation processes. Participants also identified four potential key challenges to interventions (ie, difficult to implement or achieve; partially formulated; exploited or misused; requires tailoring for context), and four key actions to help support intervention delivery (ie, coordinate and cooperate with stakeholders; invest in civil society; create a social movement; nurture leadership).

CONCLUSION

A systems thinking lens revealed the theoretical interdependence between disparate and heterogenous interventions. This suggests that to be effective, interventions need to align, work collectively, and be applied synchronously to different parts of the system, including multiple levels of governance. Importantly, these interventions need to be supported by intermediary actions to be achieved. Urgent action is now required to strengthen healthy alliances and implement interventions.

Designing for a Healthier Indore, India: Participatory Systems Mapping

In Indore, India, BHC engaged 247 multi-sector stakeholders through a systems mapping approach to gather qualitative data across three workshops and four citizen town halls from 2018 to 2020. These data were synthesized with results from BHC's 18 other city activities to build a systems map and identify high-impact areas for engagement. Contextual findings showed a tension at the heart of Indore's growth-Indore's great success as a city has spurred rapid population growth. This growth creates pressure on municipal systems as population outpaces service delivery capacity. This is central to the systems map that BHC developed and is expanded upon through additional patterns that fall within four main domains: (1) leadership, governance, and financing; (2) essential service delivery and workforce; (3) information systems; and (4) community infrastructure and education. Stakeholders found three key leverage opportunities within this context that, if included in every action, could help overcome barriers. These opportunities are: (1) improving data quality, use, and integration; (2) supporting accountability to, and enforcement of, policies and regulations; and (3) increasing community engagement. Brought together through a better understanding of the key patterns driving system behavior from the context map and leverage opportunities, BHC was able to co-create, with stakeholders, seven "coherent actions" to move Indore to a healthier, more equitable state. When COVID-19 regulations ease, BHC and city officials will reconvene to finalize an implementation plan for these actions.

Designing for a Healthier Makassar, Indonesia: Participatory Systems Mapping

In Makassar, Indonesia, the USAID-funded Building Healthy Cities (BHC) project engaged 240 multi-sector stakeholders to gather qualitative data across three workshops and two citizen town halls from 2019 to 2021. These data were synthesized with results from BHC's nine other Makassar activities to build maps of the current system and identify high-impact areas for engagement. Contextual findings showed that Makassar leadership has actively innovated and used new technology to improve the city, resulting in improved connectivity and responsiveness. However, this drive toward innovation has strained existing infrastructure and workforce capacity. When this strain fails to meet promised results, citizens are less likely to engage and support the innovations. This is central to the systems map that BHC developed, and is expanded upon through additional patterns that fall within four main areas: (1) leadership, governance, and financing; (2) infrastructure and workforce; (3) collaboration and data; and (4) community cohesion and awareness. Stakeholders found three key leverage points within this context that, if included in every action, could help overcome barriers. These leverage opportunities are: (1) increasing data-driven decision-making; (2) ensuring equitable policy and leadership; and (3) increasing community participation. By combining key patterns discovered in the Context Map with the leverage opportunities, BHC was able to co-create with stakeholders six "coherent actions" that can move Makassar to a healthier, "Sombere (kind-hearted and hospitable) and Smart City." BHC has been working with the city planning office to incorporate the map findings into its bottom-up planning processes and the 5-year mid-term plan for Makassar.