Complex Systems Change Starts with Those Who Use the Systems

Philanthropy, especially in the United States and Europe, is increasingly espousing the idea that transformative shifts in social care, education, and health systems are needed. Yet successful examples of systems-level reform are rare. Concepts such as collective impact (funder-driven, cross-sector collaboration), implementation science (methods to promote the systematic uptake of research findings), and catalytic philanthropy (funders playing a powerful role in mobilizing fundamental reforms) have gained prominence as pathways to this kind of change. These approaches tend to characterize philanthropy—usually foundations—as the central, heroic actor. Meanwhile, research on change within social and health services continues to indicate that deeply ingrained beliefs and practices, such as overly medicalized models of care for people with intellectual disabilities, and existing resource distribution, which often maintains the pay and conditions of professional groups, inhibits the introduction of reform into complex systems. A recent report by RAND, for example, showed that a $1 billion, seven-year initiative to improve teacher performance failed, and cited the complexity of the system and practitioners’ resistance to change as possible explanations. 

We believe the most effective way to promote systems-level social change is to place the voices of people who use social services—the people for whom change matters most—at the center of change processes. But while many philanthropic organizations tout the importance of listening to the “end beneficiaries” or “service users,” the practice nevertheless remains an underutilized methodology for countering systemic obstacles to change and, ultimately, reforming complex systems.

After a decade of experience instigating public-private collaborations in Europe and elsewhere, we believe philanthropic efforts to change systems continue to be far too focused on solutions developed in idealized contexts, where organizations assume away the implementation challenges of the wider system. Often foundations seek to influence education, social care, and health systems without a clear strategy for how the new innovations will actually result in change. Here is a look at why we believe this problem persists, as well as some observations and lessons that can help funders achieve meaningful results. In particular, we have observed that bringing the people using services into reform efforts greatly informs the design of services and helps overcome some of the obstacles that prevent systems from changing (such as the dominance of professional groups in shaping services).

The myth of philanthropy as the primary catalyst for change

One of the most enduring myths in philanthropy is that foundations should play the leading role in reforming social services. Foundations often see social service providers—both public services and NGOs—primarily as the implementers of solutions developed in isolation. They place less emphasis on understanding the internal dynamics of the organizational fields—such as competing demands for resources and profile between NGOs and medical and educational professionals, or the challenges policymakers face in reallocating resources in highly unionized environments.

This status quo is based on two unhelpful beliefs:

• That the main barrier to systems-level change is lack of innovation. This is a view that the field should adopt and scale “best practice” solutions developed through research, in other geographies, or in demonstration settings, rather than working from within existing services to overcome the real challenges of implementation.
• That participants in any given effort will trust funders as neutral brokers with the authority to bring together the field, establish reason and clarity around objectives, and divvy up responsibilities. More-sophisticated versions of this involve funders sponsoring facilitation and scenario planning to get these organizations to work together.

Toward a more realistic, curious, collaborative approach to scaling change

Instead of perpetuating these myths, we suggest that foundations and others looking to collaborate toward systems change prioritize the following five practices:

1. Recognize and learn about the challenges within the system you’re seeking to reform. In the early stages of a collaboration, it is important to get to know how various groups and individuals view the challenges of a given system, and what they see as appropriate ways to overcome them. In homeless services, for example, resources are often tied up in emergency-type responses (such as overnight hostels) that do little to move people into secure tenancies. Yet many international evaluations have shown the effectiveness of housing-first approaches that consult with service users.

An “action-learning” approach has often proved invaluable to our work in this area. It involves interviewing different groups independently, and then grouping their responses (in a non-attributable way) to see various interpretations of progress, emerging challenges, and potential solutions. In this way, collaborators—assisted by independent facilitation—can bring potentially sensitive, seemingly undiscussable issues to the table and deal with them in constructive ways. Action learning enables service users and practitioners to reshape and amend their model or innovation in line with what is achievable, and is more adaptable and incremental than other approaches to reform.

2. Set an example. Putting users’ at the heart of design, delivery, and evaluation also models helpful behavior for the wider system. Asking someone who has used mental health services, for example, to help assess proposals for medical reform funding shifts the status-quo power dynamic; it signals that new services are not simply the preserve of medical professionals, and that the wishes and needs of the people using them are valued. This can help reduce paternalistic attitudes among service providers and help service users become more assertive and confident about sharing their experiences with services.

3. Build out from a coalition of the willing. Leaders who work within social service systems and who are acutely aware of—and frustrated by—the challenges of implementing reform are often the greatest champions of this approach. Professionals, managers, and carers often find a mismatch between available service options and what service users really need. Identifying a coalition of supporters and building out from within the system (rather than testing a pilot program externally and then campaigning for its introduction into the systems) tends to appeal to sceptical senior staff, who often are weary of bright ideas they can’t actually apply. Working out from pockets of best practice within the system shows that you can make progress despite the challenges.

4. Start small. Since the economic recession of 2008, many social service systems have been operating on even leaner-than-usual budgets and facing increasing demands. Small amounts of funding, allocated using clear criteria to instigate reforms, is often a good way to encourage service user involvement, and to uncover early adopters and innovative leaders from within social service systems. In our work supporting mental health service reform in Ireland, for example, we required that providers develop services in partnership with service users before they could qualify for additional funding. This requirement meant providers seeking funding had to embed service users’ views into their reform processes, both at the beginning and as they progressed.

5. Take credit only when necessary. Overtly branding a reform effort as a foundation’s initiative can alienate and demotivate service users and other collaborators. It implies that the reform is coming from the outside. It is better for funders to work collaboratively on the inside of systems from the beginning, without too much concern for attribution, and later shine the light of positive progress on others, many of whom can use this affirmation to make the case for expanding the effort. This creates better conditions for ownership by those who will have ongoing responsibility for sustaining and scaling change. For example, our organization’s work in Ireland has a very low public profile to ensure that credit goes to people who use services, practitioners, and leaders in health and social care fields where we operate.

In our experience, these practices have been more effective than “toolkit” or “playbook” approaches, which often assume that collaborative, systems-level change is less complex than it is and that all involved will share the same willingness to push for change. Putting people using services at the core of reform means seeking users’ regular involvement in decision-making, and having staff develop curiosity and respect for the wishes and capacities of the people they support. When this does not happen, you get expensive systems that provide services people do not want or use.

Involving service users in the design of services, and in decisions about the allocation of resources, can help “unfreeze” assumptions providers make. It can also highlight why providers need to reallocate resources to services that better meet service users’ needs. In the end, real change is simply more likely to happen when we put those for whom change matters most at the center of the process.

Read more stories by Madeleine Clarke & John Healy.