(Photo by iStock/oatawa)
The news in December 2020 was filled with hopeful stories about the arrival of safe and effective COVID-19 vaccines. Yet the end of the pandemic remains a significant distance away. As of today, no group or institution—no corporation, business consortium, government entity, or international agency—can single-handedly design and implement a system to provide the vaccine to all seven billion people on Earth. In the United States, the lack of planning for vaccine delivery may be even more stark: While the United States is mounting the largest vaccination development effort in history, there is a serious lack of strategy for building trust and for distributing the vaccine, especially to the most-marginalized and highest-risk populations. Meanwhile, enormous problems driven by the ongoing spread of the virus—including shortages of vital medical equipment, overwhelmed hospital emergency rooms, and the massive human suffering resulting from shut down businesses and schools—continue to fester.
When we face a problem this big and this complicated, people and organizations must work together to diagnose it, then design, plan, implement, and coordinate disparate activities across every social and economic sector to solve it. In other words, we need to build coalitions that can create systems-level change.
Traditional Systems Can’t Fix Themselves
The pandemic has helped make the inadequacy of many existing systems obvious. We now see:
- How easily regimes uninterested in transparency can stymie international systems for monitoring and sharing data about global health threats
- How quickly a fast-moving infection can overwhelm health-care systems in supposedly “advanced” societies
- How relying on global supply chains organized on a just-in-time basis for essential health-care equipment can leave entire countries vulnerable
- How poorly the United States in particular supports and protects the health care system and essential workers it depends on in times of emergency
- How safety nets intended to provide the minimum underpinning for crucial social determinants of health—food, housing, and jobs—are deeply fragile and flawed
- How marginalized populations—people of color, the poor, the elderly, the disabled, and the isolated—are particularly vulnerable when a crisis wreaks havoc on our social and economic structures
Our traditional systems have enabled the spread of COVID-19 and interfered with our ability to address it. But those systems can’t fix themselves, and no organization or person has the capacity or skills to design and put in place a new, top-down system that solves these numerous, complex, and interconnected failures. And while each of the institutions involved in these failures needs its own reform program, we can’t put the COVID-19 challenge on hold until that happens.
Instead, we need to take a systems-level approach that engages “top-around” coordinators, or “orchestrators”—individuals or organizations that foster timely, effective cross-sector partnerships and activate new allies to produce outcomes existing institutions can’t achieve. In the words of MIT lecturer Peter Senge, these kinds of systems-shaping leaders have “the ability to see the larger system … [which] enables collaborating organizations to jointly develop solutions not evident to any of them individually.” Rather than telling people what to do, orchestrators build consensus, identify opportunities for collaboration, share best practices, and measure progress; they typically have very little formal power but can unify others around a common agenda.
Cross-Sector Partnerships for Systems-Level Change
Though solving a problem like the COVID-19 pandemic is far from simple, some pioneering, systems-level projects in other fields have shown the way. For example, the nonprofit Malaria No More is orchestrating a systems-level initiative to tackle the worldwide challenge of combatting the disease; a multipronged effort supported by Community Solutions has sharply reduced homelessness in more than 80 US cities and communities; the McConnell Foundation is leading an effort to slash poverty in Canada; and a collection of partners that includes the PEW Foundation is addressing environmental damage to the world’s oceans.
As with the problems these initiatives are facing, dealing with COVID-19 requires an unusual degree of cooperation, information-sharing, joint decision-making, and systemic reform across sectors, mostly reliant on voluntary partnership rather than formal or legal authority. There’s no pandemic “czar” with the absolute power to dictate a response. With this in mind, several initiatives targeting the pandemic are taking a systems-level, multi-player approach, and are already proving more effective than individual efforts of traditional health-care leaders like the Centers for Disease Control.
One US-based example is the National Governors Association’s pandemic response program, which both of us support as funders. This bipartisan network of governors and their staff is working on concrete, coordinated solutions to immediate problems created by COVID-19, as well as building capacity for long-term pandemic response efforts. For example, the NGA team—together with a crisis-response unit of the Defense Department called the Joint Task Force, several health-care nonprofits, and a group of analysts and sourcing professionals—is developing systems for coordinating the purchase and distribution of essential supplies like ventilators and personal protective equipment. The NGA team is also creating new public-private partnerships to expand testing capacities, intensifying cooperation with NGOs that have expertise and experience in activities like contact tracing, and teaming up with the private sector to develop and implement plans for safely reopening sectors of the economy. As orchestrator of the effort, NGA Center for Best Practices Director Timothy Blute helps ensure that partners communicate and share best practices, in part by presiding over weekly coordinating sessions between governors and their staffs.
Some organizations are orchestrating more targeted collaborative efforts that still embrace systems-level principles. For example, the nonprofit United States of Care helps provide federal and state officials with immediate access to scientific experts, current research, policy recommendations, and best practices for combating the virus. The Institute for Healthcare Improvement has created tools for policy makers, including a COVID-19 data dashboard that uses sophisticated modeling techniques to quickly identify where spikes in infections are occurring. In addition, the Association of State and Territorial Health Officials has developed resources such as a four-part training program for the thousands of contact tracers now needed to control the spread of the virus, and National Association of County and City Health Officials has created a dedicated COVID-19 Virtual Community where local health officials can share questions, data, information, and resources that can help communities combat the disease. In each of these cases, an organization rooted in a specific sector, such as a government agency or a nonprofit group, is coordinating information, ideas, and activities with other organizations in different sectors, helping produce results no single group could hope to achieve alone.
The seriousness and complexity of the COVID crisis, along with the failure of the federal government to play a strong coordinating role, have prompted organizations like the ones we’ve described to apply a variety of systems-level change principles. These can be helpful across a range of complex problems, and they include:
- Start the initiative by convening organizations and individual leaders from every sector (government, nonprofits, business, academia, and philanthropy), sharing notes on what each participant is doing and what others are doing, and honestly assessing what’s working and what’s not.
- Identify effective solutions but don’t fall in love with any one program. Serving varying populations, geographies, and time frames, and supporting experiments to quickly identify and distribute solutions, requires many tools.
- Communicate, communicate, communicate! Once the initiative launches, set up weekly conference calls, and circulate frequent summaries of innovations, ideas, and needs. Share new developments involving partners and others active in the field in a timely way so that every participant can shift strategies as needed.
- Don’t worry about who gets the credit or who others view as “in charge.” Systems-level initiatives work best when leadership is widely distributed and when everyone with a good idea gets an equal chance to contribute.
Activating Neglected Resources for Systems-Level Change
In addition to actively fostering cross-sector collaboration, orchestrators of systems-level change need to seek out people or groups who have the skills, background, knowledge, and willingness to fill urgent needs, but who have been stymied by systemic inertia, cultural differences, or economic inequities. Finding ways to draw in these neglected players and provide them with the resources they need—and, equally important, the systemic “permission”—to make their vital contributions. Thus, one of the central roles systems-change orchestrators play is to break down the organizational and sector-based barriers that often prevent groups from working together productively, by providing the space and language for diverse contributions.
Community health workers (CHWs), for example, have long been overlooked and under-resourced members of the US health-care system. At the onset of the pandemic, even as most state-run contact tracing programs were proving ineffective, they received just a tiny fraction of the federal relief funds flowing to the states, despite being especially well-positioned (by virtue of their deep community roots as locally based family caregivers) to manage the contract tracing tasks that can dramatically slow the spread of the virus.
In response, some 15 organizations (including ours) came together to form the Community-Based Workforce Alliance (CBWA), with the aim of integrating trusted CHWs into pandemic response efforts such as contact tracing, testing coordination, and planning for vaccine rollout. In fall 2020, through engagement with policy makers and public health officials, the CBWA started discussions about how CHWs could build trust and overcome latent vaccine hesitancy in the communities most vulnerable to the COVID-19. One specific outcome was a broadly endorsed “Joint Statement On Ensuring Racial Equity In The Development And Distribution Of A COVID-19 Vaccine.” Another was a forthcoming, web-based platform to channel vaccine-related information to community-based organizations and local health departments serving vulnerable populations.
Meanwhile, the Community Health Impact Coalition (CHIC)—another partnership we helped found and support, and which CHIC Co-founder and Executive Director Madeleine Ballard orchestrates—plays a similar supporting role in activating neglected community-health resources. It represents a new kind of organizational model, shaped by systems thinking, in which CHIC gathers and shares knowledge, and supports NGOs in coordinating their efforts and scaling innovations at the country- and continent-wide levels. The organization is currently coordinating a wide array of efforts to combat the COVID-19 pandemic, including channeling philanthropic funds to CHW programs to help them manage overwhelming demand, and unify and strengthen their collective voice.
Groups like these are helping community health workers gain recognition, and integrating their efforts into the reform and strengthening of health care services. They also illustrate two additional, systems-level change principles:
- When efforts to solve a complex problem are foundering, look for underutilized resources that might help produce a breakthrough.
- Create or deploy small orchestrating organizations to bring groups together, then share goals, ideas, problems, and solutions to create a common vision.
In addition to the initiatives above, two major projects focused on vaccine development and distribution deserve mention. One is Operation Warp Speed, a $10 billion program that brought together hundreds of individuals and dozens of agencies, most of them housed in either the Department of Defense or the Department of Health and Human Services, to expedite the delivery of a COVID-19 vaccine to hundreds of millions of Americans. The other is the World Health Organization COVID Response project, led by Sir Andrew Witty, former CEO of pharma giant GlaxoSmithKline. This project includes an array of global health-care industry organizations, heads of state from a dozen countries, and nonprofits like the Bill & Melinda Gates Foundation. Its goal to forge an effective partnership that will ensure “equitable global access” to the vaccine.
These two ambitious projects are further examples of the kind of systems-level change efforts COVID-19 demands. When systemic problems go unsolved because potentially powerful resources suffer from lack recognition, inadequate funding, poor coordination of effort, needless competition among rival groups, or other problems, leadership by systems-level change orchestrators can help.
Beyond the Pandemic: Sustaining New Systems
Systems-level change is about more than standing up temporary networks or systems that will shut down when an emergency passes. It’s about creating improved social, economic, political, and technical systems, processes, and networks of connections that are truly integrated into the broader societal framework and capable of outlasting particular short-term issues. We need governments at all levels, foundations, universities, and other funding organizations to help identify, train, and support groups and individuals whose mission is to orchestrate the systems-level changes necessary to ensure health and resilience for their communities. Embedding these orchestrators in organizations that can coordinate change and recruiting funders to provide the modest sums needed to support them are important first steps. Only through initiatives like these can we successfully conquer the COVID-19 pandemic, as well as the unknown crises that tomorrow will surely bring.
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Read more stories by Jeff Walker & English Sall.