Systems leadership for sustainable change
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To lead change in eye health, we must first understand the system we’re trying to change.
In our previous article “Leadership for 2030 In Sight” we outlined the need for a new kind of leadership in eye health, and introduced a core set of skills needed to drive transformative change. This article explores the first of those skills: systems thinking.
What is systems thinking? What do we mean by “the system”, and how does it relate to leadership?
Eye health as a complex system
Eye health does not exist in isolation. It is part of a complex system made up of interconnected people, organisations, and institutions, each with theirown goals, challenges, and ways of working. These elements interact in unpredictable ways, shaped by policies, financing, service delivery, workforce dynamics, social beliefs, and individual behaviours. No single perspective can capture the full picture. Imagine viewing a large painting with only a small torch: you can only see part of it, making it hard to understand the whole.
Most of us engage with just one part of this system, as clinicians, programme managers, advocates, or policymakers. While the WHO Health Systems Framework identifies components like service delivery or governance, it’s the interconnections between these components – and with broader social and economic forces – that shape patient outcomes.
For example, a policy shift in insurance or government funding can ripple through the system, affecting service availability, medication costs, and even public awareness. A patient’s decision to seek care might hinge on family support, workplace incentives, or social beliefs. These interdependencies mean that outcomes in eye health are rarely linear, requiring adaptable approaches.
Understanding how all these factors interact gives us more choices and ideas about how to make improvements. To strengthen access and quality, we need a mindset that works with – not against – this complexity.
Shifting mindsets: leading as a systems activist
Eye health leaders face challenges like unequal access to care, resource constraints, and rising need. In such environments, isolated interventions won’t work. Instead, we must understand the wider system and collaborate across boundaries to co-create solutions.
Systems leadership offers a framework for doing this. It’s not about authority or position; it’s about perspective, influence, and the ability to mobilise others around shared goals. Useful resources include Donella Meadows’ work on systems change1, Systems Leadership for Sustainable Development from The Harvard Kennedy School,2 and the seminal article The Dawn of Systems Leadership in Standford Social Innovation Review.3
IAPB has identified four mindset shifts that support systems leadership in eye health:
• From health to the whole of society. Addressing not just clinical issues, but the social, economic, and environmental factors that shape eye health.
• From programmes to policy. Influencing policy for long-term impact rather than focusing solely on programme delivery.
• From competition to collective impact. Collaborating rather than working in silos.
• From management to mobilisation. Enabling action through shared ownership, rather than relying on top-down control.
These shifts offer a powerful lens through which eye health professionals – at all levels – can see their work differently and lead more effectively.
Case study: systems leadership in action in Bangladesh
A recent initiative in Bangladesh illustrates these mindset shifts in practice. The Fred Hollows Foundation, an IAPB member, applied systems leadership to drive national level change aligned with 2030 In Sight.
The initiative began with a system mapping workshop to identify the many interdependencies affecting access to eye care, as well as opportunities for collaboration (see Figure 1). This brought together diverse stakeholders and laid the foundation for joint action: moving from competition to collective impact.
One key insight from the mapping process was that of seeing eye health as a workforce issue. In a follow-up workshop, participants agreed to engage with the garment industry – Bangladesh’s largest export sector, employing over 4 million workers – 80% of whom are women.4 This represents a shift from a narrow health perspective to a whole of society approach, which recognised the economic and gender dimensions of access to health care.
The initiative aligned with the interests of industry stakeholders and created momentum for change. International NGOs are now collaborating with the Bangladesh Garment Manufacturers and Exporters Association (BGMEA) to integrate eye care into workplace health services across 4,500 factories. The next step will be agreeing on a model of care, followed by the development of a sustainable financing plan and an initial pilot in 200 factories. This represents a shift from isolated services to sector-wide policy change—moving from programmes to policy.
Beyond these immediate outcomes, the initiative fostered new relationships and a sense of shared ownership. It catalysed the emergence of a community of practice committed to systemic change.
To sustain this momentum, the United Nations Development Programme (UNDP) in Bangladesh – supported by The Fred Hollows Foundation – is creating a dedicated role for someone who will nurture cross-sector collaboration. This exemplifies the shift from management to mobilisation: moving from project-based control to enabling networks of changemakers.
What does this mean for eye health professionals?
The Bangladesh case study shows how systems leadership can lead to sustainable improvements in eye health. But systems leadership is not only for those leading national programmes. It’s a mindset that anyone in eye health can adopt.
It means looking beyond day-to-day responsibilities to understand how your work fits into the bigger picture. It might involve building relationships with other sectors, engaging your community, or rethinking how to address everyday challenges.
We know time and resource constraints can make this challenging. But with vision loss still affecting so many, we urgently need new approaches to leading change.
Eye health professionals bring deep expertise and community trust. By adopting a systems leadership approach, you can use your unique strengths to influence change beyond the clinic. This means working collaboratively, thinking long-term, and embracing continuous learning and adaptation.
Wherever you are working, and whatever your role, you can help shift the system, and be part of the global movement to achieve eye health for all.
ACTION STEP
To start preparing for the next article in this series on creating a shared vision for change, re-connect with your organisation’s vision. If it doesn’t have one, perhaps invite people you work with – clinicians, managers, community leaders, advocates – to reflect on their shared purpose. Try the question: “What future are we working towards, and what matters most to get us there?”
You can also:
• Reconnect with the vision, mission, and priorities of the sector strategy 2030 In Sight in the summary document: bit.ly/3G4qoa4
• Explore this article about creating a shared vision for change from The Systems Thinker: bit.ly/4kpw3TP
References
1. https://donellameadows.org/archives/dancing-with-systems/
2. Dreier, Nabarro, Nelson, 2019, Systems Leadership for Sustainable Development, Strategies for Achieving Systemic Change https://www.hks.harvard.edu/sites/default/files/centers/mrcbg/files/Systems%20Leadership.pdf
3. Senge, Hamilton, & Karia, 2015, The Dawn of Systems Leadership https://ssir.org/articles/entry/the_dawn_of_system_leadership
4. Understanding the Gender Composition and Experience of Ready-Made Garment (RMG) Workers in Bangladesh, International Labour Organisation and UN Women Issue brief, 2020