This course provides an introduction to systems thinking and systems models in public health. Problems in public health and health policy tend to be complex with many actors, institutions and risk factors involved. If an outcome depends on many interacting and adaptive parts and actors the outcome cannot be analyzed or predicted with traditional statistical methods. Systems thinking is a core skill in public health and helps health policymakers build programs and policies that are aware of and prepared for unintended consequences. An important part of systems thinking is the practice to integrate multiple perspectives and synthesize them into a framework or model that can describe and predict the various ways in which a system might react to policy change. Systems thinking and systems models devise strategies to account for real world complexities. This work was coordinated by the Alliance for Health Policy and Systems Research, the World Health Organization, with the aid of a grant from the International Development Research Centre, Ottawa, Canada. Additional support was provided by the Department for International Development (DFID) through a grant (PO5467) to Future Health Systems research consortium. © World Health Organization 2014 All rights reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Johns Hopkins University Bloomberg School of Public Health has a non-exclusive license to use and reproduce the material.
Lecture 8A: How Systems Thinking Can Contribute to Policy Decision Making
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Systems Thinking In Public Health
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Practical and policy implications
This Module wraps up the course and shows you how systems thinking can contribute to policy making.
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David Bishai, MD, PhDProfessor
Population, Family and Reproductive Health
Ligia Paina, PhDAssistant Scientist
International Health
[MUSIC]
Welcome, this is Professor David Bishai and this is a lecture on how
model based analysis can contribute to policy decision making.
The outline for this lecture is in four sections.
First, we're going to cover the nature of sustainable policies.
And second, we're going to go through the top-down version of systems thinking, and
then a bottom-up version of systems thinking.
And then finally offer an integration and summary.
I just wanted to focus on the theme throughout this lecture
which is the concept of the ecostructure.
The ecostructure is a term that Colander and Kupers have introduced in their book.
Complexity and the art of public policy.
Ecostructure is a word that defines the set of expectations and
norms about what everybody thinks policymakers are supposed to be doing.
The ecostructure determines how he policy makers and
the citizens and the technocrats view themselves.
What they think they're supposed to be doing and it can be changed.
So for example, Louie XIV, his ecostructure is summarized
in his quote [FOREIGN] meaning, I am the state, because for
a monarch like Louie XIV, he was the policy making machine and
the subjects of France exist to serve his needs and interests.
And there was no role for citizens or technocrats.
But that changed and ecostructures can be changed.
And so throughout this lecture we're going to talk about
ecostructure from the top down, from the bottom up, and how with systems thinking
we are trying to move into changing these expectations and
norms about the nature of the policy problem and the policy making problem.
So, in Section A, I want to talk about the Nature of Sustainable Policies.
And I'm going to do this using an important case study
in history of public health.
I want to tell you about Professor Abel Wolman.
Professor Wolman was voted as one of the Marylanders of the Century
by the Baltimore Sun in the year 1999.
He was truly a giant in public health.
He joined the Johns Hopkins faculty in 1937.
And founded that the Department of Environmental Engineering.
And prior to his arrival at Johns Hopkins he served as the State of Maryland
chief engineer.
And he is famous for having invented water chlorination but
not only that, developing a changed
ecostructure that helped spread municipal water supplies throughout America.
The graph shown in this slide is Wolman's own graph showing how the decline of
typhoid, that down going line marked with a T, happened at the same time
as the improvement in water supplies, which is the upward line marked with an S.
And Wolman, probably pretty persuasive in suggesting that there was a correlation
between municipal water and the decline of typhoid fever.
So his problem after he invented water chlorination and
realized that he had to chlorinate water in a municipal water
system rather than in individual wells was how to get people to pay for it.
These were expensive public works undertakings.
And the way I think you or I would think about it would be the obvious hey,
everybody will get less typhoid and
diarrhea if we build a municipal water system.
And hey, it would be way easier just
to be on a municipal water supply rather than have to deal with your own well.
Obviously Wolman and you and I would be mindful that there's a tax consequence
but Wolman learned quickly in his work that tax incidence wasn't in his uniform.
That typically there was a property owner that owned
large amounts of property in any given city.
And they were the ones that were the hardest to convince.
They would pay a lot in property taxes, and
it wasn't clear to them why they should support it.
So Woman in 1918, when he was working for
the state of Maryland, he found that he was having trouble.
So he went to Elkton, Maryland which was one of the most in need
cities in Maryland, where the typhoid death rate was the highest in the state at
50 per 100,000 and enormous epidemiologic rate.
So he gives them the typical talk, telling them how they had a lot of
typhoid fever and they should build a municipal water supply.
Well the mayor and the city counselors were polite, but they sent him on his way,
unimpressed with the need to build a municipal water supply.
So Wolman got smart.
He sent his staff to draw a map of the city of Elkton.
This wasn't a map of where to put the taps for residential water.
He built a firefighter's map of the water supply and
where the fire hydrants would be.
He had his engineers build the size of the water main so
that they would deliver a certain pressure to put out a fire.
So after he drew this map of Elkton, he realized quickly that the hydrants would
be serving property owners throughout the city.
But not only that, 30% of the properties in Elkton were owned by one landlord.
This would be like an Old Man Potter in It's A Wonderful Life.
And every city has this kind of landlord who owns most of the city but
isn't widely impressed with social causes.
Wolman went back to Elkton, Maryland and met with the mayor and
the city council again but he also met with the landlord guy,
that Old Man Potter, and he presented them this fun fact.
That if they built a municipal water supply the fire insurance bill on
city property would go down by twenty five percent every single year and
most of that money would be saved by the big landlord.
The insurance savings alone could pay off the bond issue in just a few years and
then the people of the city would just be enjoying the maintenance cost of
keeping up the the municipal water supply.
That worked and Elkton bought it and Wolman's whole mission for
the rest of his career as a water engineer.
He stopped talking about typhoid fever and
forever after he kept talking about fire hydrants.
And indeed the American water supply system uses
pipes that are way bigger than they need to be if all we want to
do is give drinking water to residential properties.
We have these huge water mains because we had to sell municipal water
supplies on the basis of their finer insurance savings properties.
But this is how we got the politics done.
And so, the lesson Wolman learned in Elkton is a lesson in ecostructure.
And Wolman, when he was reflecting back on those years after he joined our faculty,
wrote down this really important quote, that the professional has and
will continue to have a prime function.
Namely the the illumination of choices for the political decision maker, and
the illumination that Wolman did was not hey there was a lot of typhoid.
It was an illumination of this is the political reality of who is making
the decisions in the city and this is what appeals to the way they see the problem.
That is the nature of illumination and that is the levels of systems thinking
that led Wolman to be successful in public health.
So what does it take for illuminated policy making to occur?
Well clearly you need to make your policy proposals
compatible with the incentives of the key stakeholders.
Public health policies by their nature are going to generate winners and losers.
We need the need the big winners to win bigger than the big losers lose.
And that's true for so many public health policies,
whether we want to tax cigarettes or close down liquor stores or
improve the density of sidewalks and physical environmental changes.
People need to be brought on board.
But the illumination has to be presented in the language they can understand.
Leading policy makers to reach their own conclusions is so
much better than condescending to them and
saying well, in my model it shows that you will benefit this much.
It's so much better to show rather than to tell, because the ideas that policy makers
arrive at at their own are so much more compelling.
Than the ideas they are told by a public health academic or professional.
So that's sort of the basic case study I'd like to build on and in the next section
we'll talk about how we can do systems thinking in a top down approach.
