A System Within a System Within a System: Unraveling the Complexities of Public Health in the US
The Complexity of Public Health
Public health is a mess of complex networks of relationships among partners who are working toward shared goals and ideals for the public’s health. The “mess” cannot be overstated, given the wide variation across the nation regarding public health authorities, services delivered, and the multitude of partners involved in this system of systems. Each partner has a variety of aims and motivations that may support or compete with public health goals. For public health to work optimally, its systems, subsystems, components, and parts need to all work in harmony.
Source: CDC, 2018. The Public Health System.
Analogy to Better Understand Public Health Systems
It is sometimes challenging for those outside of the public health sector to understand the systems of systems in place for public health. I use the following analogy to compare systems we may be more familiar with—automobile systems—to certain aspects of public health systems.
Source: Welleman, CC BY-SA 3.0, via Wikimedia Commons
Engine System – Public Health Department
An engine is an excellent metaphor for the public health department, as governmental public health is often the central authority and driving force to improve the health of the population. The vehicle’s engine is its main source of power, changing chemical or electrical energy (fuel) into mechanical energy (drive). The engine also incorporates other subsystems for lubrication (oil) and cooling (coolant) to make sure all components work efficiently and effectively.
Health priorities of communities fuel health departments’ work to improve health. Health departments also supply opportunities for involvement such as for those working to provide access to services (like engine oil) and volunteers (like engine coolant). As a jurisdiction’s “Chief Health Strategist,” the health department is well-suited to lead the transformation of health priorities into health improvement plans and community health policy.
Drivetrain – Service Delivery Agents
A vehicle’s drivetrain transmits the engine’s power to the vehicle’s wheels for propulsion, which may be a metaphor for how health departments and different system partners (“agents”) may deliver services. The drivetrain includes transmission to modulate speed, drive shafts to translate power, and other components to move the vehicle forward. This system encompasses multiple components and moving parts which act toward the driver’s goal.
In public health, partners or agents may be from public or private agencies (e.g., governmental public health, non-profit community health center) and may hail from s sectors such as public health, health care, and social services. Partnerships may be configured in a variety of ways, such as through cross-jurisdictional service sharing, cross-jurisdictional delivery of services, or cross-sectoral collaboration between public health, health care, and social services. As in a vehicle, each part has its unique contribution to the system and different components offer different performance and other characteristics that influence the efficiency and effectiveness of the system and its forward momentum.
Suspension/Support System – Service and Resource Sharing
The suspension and support systems are determinants of ride and handling, which may be a metaphor for how partner relationships and policy frameworks ensure smooth operations. The suspension and support system maintains the relationship between the wheels and the vehicle frame and works with the steering system to provide vehicle control, absorbing energy and maintaining stability. These systems also work to prevent wear and damage to other vehicle systems.
Policies and agreements, both formal and informal, offer guidelines and connections for services and partners involved in delivering them. The relationships forged in service or resource sharing, such as cross-jurisdictional sharing and public-private partnerships, supply support to ensure smooth delivery. Formal agreements are important for when things do not go as planned and offer frameworks for getting back on track, ideally preventing breakage in relationships. Sharing and delivery arrangements each support sustainability of efforts and offer a buffer against resource constraints.
Steering Systems – Advisory and Governance Bodies
Steering systems supply direction for the vehicle and allow it to arrive where intended, which may be a metaphor for leadership in public health. Steering systems in modern vehicles both direct the vehicle and monitor direction and indicate when the vehicle may be off-track. In a vehicle, other systems are in place to monitor whether the vehicle is on track, such as “lane assist” technologies and automated steering adjustments. These subsystems provide other automated guardrails or course corrects for the vehicle.
The leadership of public health involves governing authorities as well as administrators and program supervisors. Governance bodies, such as boards of county commissioners, are the ultimate authority and decision-making entities for public health. These bodies are supported by advisory councils which supply guidance to public health entities. Governance may be shared, however, within configurations of partners and may dictate the service and resource sharing arrangements that may be in place. Administrators and supervisors also provide direction to steer the delivery of services and, in concert with advisory bodies, may monitor the health of the community and identify gaps to be addressed by public health.
Frame and Body – Legal Infrastructure
The frame and body provide the foundation on which to build the vehicle, like the role of legal infrastructure in public health. The vehicle’s frame and body both address objectives of passenger safety and protection of vehicle systems. They also hold the different systems in their proper places.
The public health legal infrastructure is a critically important foundation and is one of the strongest determinants of impact for public health. A weak legal infrastructure may lack well-defined requirements for public health services or have gaps in authorization of certain public health services. This creates a poor foundations for population health work and inadequate protection of the public’s health. A strong legal infrastructure is supportive of the public’s health. Improvements to the legal infrastructure, such as through public health “modernization” efforts, lead to overhauls in public health laws and systems transformation.
Electrical System – Coalitions, Information Systems, Champions
The electrical system supplies energy and communications for the disparate systems across a vehicle, analogous to interpersonal communications. A vehicle’s electrical system includes the ignition and charging subsystems as well as an electric motor and alternator. These different subsystems allow for communications between systems and delivery of input signals to initiate and coordinate actions.
There are many ways in which direction and communications are dispersed throughout a community. Coalitions of many agencies across sectors may contribute to communications efforts and create networks for information sharing. Certain leaders and visionaries, often in coalitions, are catalysts to change and are held as “champions” to “ignite” change and initiate community activity. Beyond information sharing in coalitions, information systems may be available that coordinate information collection and sharing.
Fuel and Ignition Systems – Advocacy Bodies, Champions
The fuel system stores and supplies fuel for the engine, noted before as community health priorities that may be coordinated by champions or advocacy bodies. For vehicles, fuel and ignition systems include a mechanical fuel pump, a carburetor, and an “Evaporative Emission System.” This system works in line with the starter/ignition subsystem which supplies the spark necessary to change chemical or electrical energy to mechanical energy.
The health priorities of communities are maintained by advocacy bodies that provide driving forces for public health services. Advocacy bodies such as membership organizations (eg, state associations of county and city health officials) or community coalitions prioritize issues and raise key gaps to be addressed. Those priorities may be translated into policy or services to be delivered by governmental public health or partner organizations.
Exhaust, Coolant, and Lubrication Systems – Change Management Processes
The exhaust system in combustion vehicles moves burnt exhaust fumes away from the vehicle while coolant and lubrication systems prevent friction or overheating, a metaphor for change management practices. Exhaust subsystems work to protect inhabitants of the car and improve efficiency of operations. The coolant system, on the other hand, includes subsystems that each contribute to reducing excess heat to protect the engine and improve overall dependability and longevity. Finally, lubrication, such as engine oil, reduces friction between moving parts to prevent damage from routine use and improve vehicle dependability and longevity.
In public health, change management processes support long-term sustainability and reliability of efforts within agencies and across systems. The exhaust system may be a metaphor for ways in which advocacy bodies and their champions continuously adjust approaches to advocate for and to promote public health, focusing resources on key priorities. The coolant system may be a metaphor for ways in which policymakers and administrators support their subordinates to retain and improve the workforce; in absence of this, staff may be prone to burnout. Lastly, lubrication systems may be metaphors for intra-organizational processes for change management such as peer mentoring and interpersonal relationships. Each of these processes work together to retain an engaged and effective workforce to address key community health priorities.
Brake System – Performance Management
Braking systems are critical safety systems to slow the vehicle relative to the force applied to a brake pedal, analogous to performance management processes. The braking system includes multiple different components to change kinetic energy to thermal energy through friction, such as brake rotors, brake pads, calipers, and a master cylinder. When the brake pedal is pressed, the master cylinder adds pressure to the brake fluid, which supplies force to the calipers to squeeze brake pads against the brake rotors, slowing the vehicle. Over time, pads and rotors may need to be renewed or replaced.
These processes are analogous to performance management programs in which course corrections occur to better achieve specified goals. Performance management, such as through continuous quality improvement activities, is necessary to maintain high performance and achieve intended impacts. At times, leaders need to “pump the brakes” when interventions are not working as intended or when resource constraints or personnel issues are present.
Addressing Systems Complexity
Whether the analogy above was accurate or resonated with you or not, it is clear that the complexity of public health presents unique challenges to the efficient and effective delivery of public health services. As opposed to a vehicle, partners within public health systems may work paradoxically, at times cooperating, competing, or operating independently in ways that may vary over time; this is in addition to the complexity inherent in dynamics of community health. In this way, the various parts of the public health enterprise may operate more as a collection than a cohesive system. Recognition of this complexity is key to finding weak points or points of leverage for which to intervene and improve. Public health systems may be complex, but we also have ways in which we can design better systems for a better tomorrow.