1. Welter, Christina R. DrPH, MPH
  2. Risley, Kristina Y. DrPH, CPCC
  3. Castillo, Grace MPH

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Now is the time for systems change leadership in public health. Emergencies such as COVID-19 plague our communities with premature, preventable, and unequal and unjust burden of morbidity and mortality, especially for communities of color. In addition to the COVID-19 pandemic, we are experiencing a climate emergency, inadequate food systems, a growing burden of mental health problems, and a rise in low-wage, precarious work.1


Rather than trying to tackle problems one by one, today's complex problems require urgent action at the systems level. Systems thinking practices and tools can help the public health community to understand the intersecting root causes of problems operating in an unstable environment; explore diverse perspectives and opportunities for change; and develop a collaborative, generative vision of the future. This vision includes racial and economic justice alongside population health improvement using anti-racist, equity-forward strategies. When applied within our public health agencies, we build a foundation for systems change and also model systems change leadership outside our organizations.


Our recent book, Leading Systems Change in Public Health: A Field Guide for Practitioners, defines and offers an inclusive process for systems change with tools for facilitating transformation. Written and edited by and for public health practitioners, this resource is grounded in key principles to lead systems change, including health equity and racial and social justice; embracing a learning mindset; personal, interpersonal, and team leadership; and community engagement. The following snapshot of overarching themes from the book will help you consider how to develop skills to apply to your public health agency's systems change journey.


Understanding Systems Change and How to Lead It

Systems change work involves looking at the underlying assumptions that drive organizational structures, processes, programs, and policies to learn where and how to focus your efforts. Deliberate and focused systems change efforts provide greater leverage to engage in work that improves the public's health.


Core principles to guide systems change work include the following:


* Approaching every change initiative through a lens of health equity and racial and social justice;


* Embracing a learning mindset, focusing on what you can learn instead of what or who is right or wrong;


* Grounding your work in meaning and deep relationships and collaboration with staff at all levels, in different units, and with diverse external partners;


* Respecting others' lived experience to establish successful initiatives; and


* Engaging in and encouraging open, honest, and vulnerable conversations.



Before jumping into any systems change work, assess the extent to which you are ready to undertake a change initiative. A readiness assessment will help you determine what resources to put in place before taking steps to move toward a desired future state. This assessment should involve obtaining perspectives from diverse staff and partners to secure different, and preferably lived and new perspectives, on change issues.


The Levels and Success Practices of Systems Change Leadership


* Build all levels of leadership. In any organization, systems change work takes place at multiple levels. All levels are important; there is no wrong place to begin, and the process for leading systems change does not have to be linear. The levels of change include individual, interpersonal, team, and organizational. Recognizing all these levels creates the foundation for systems change leadership in public health.


* Work with employees to develop their leadership potential. Employees want to engage in purposeful work that aligns with their values and strengths. Focus on developing employees' natural leadership abilities and emotional intelligence, which will allow them to contribute more actively to change initiatives. Remember that all employees have unique perspectives and valuable input to contribute.


* Provide opportunities for employees to enhance their communication with one another. Developing social intelligence is essential. Employees who are taught how to communicate with one another, including skills such as expressing empathy and engaging in meaningful conversation, inspire new ideas and ways of thinking. When conflict inevitably arises, employees will have the skills to both align around what matters beyond the conflict and identify actions to support what matters.


* Use a racial equity framework to guide systems change within your organization. Commit to ensuring that organizational policies and procedures and programs are established with an equity lens and that all work includes diverse stakeholders. This leads to the creation of high-functioning teams that embrace expansive thinking, diverse perspectives, and new ideas.


The Process to Lead Systems Change


* Embrace a collaborative mindset. Systems change work with communities is a mindset as well as a skill set. The mindset involves a commitment to diverse participation from the onset; the belief that leadership happens at all levels; collaborative, nonjudgmental learning; and a focus on questions rather than answers so as not to rush to unsubstantiated solutions. With a shared understanding and embrace of this mindset, systems change work has the potential to result in transformation.


* Seek to explore and ask questions to define a shared understanding of the opportunity. Systems change skills include asking questions to uncover the roots of problems. Asking questions will help you gain a deeper understanding of how people perceive problems. This process involves listening to different perspectives regarding how problems are defined and then addressed, determining the extent to which the same definitions are used for common issues and terms. Through such deep listening, you can find common ground for working collaboratively and implementing sustainable improvements.


* Identify opportunities for collaborative action and implementation that sustain the work. Because systems changes are complex, implementing approaches to address these issues requires careful appraisal to select innovations that are well suited for your context. This requires working together to understand the respective and interrelated factors that influence how systems change is implemented. Multiple innovations and interventions may be needed to achieve a collaborative vision of the future systems change.


The co-editors of Leading Systems Change in Public Health: A Field Guide for Practitioners are Kristina Y. Risley, DrPH, CPCC; Christina R. Welter, DrPH, MPH; Grace Castillo, MPH; and Brian C. Castrucci, DrPH, MA.




1. Freudenberg N. A public health agenda for the 2020s [Editorial]. Am J Public Health. 2021;111(10):1757-1760. [Context Link]