What a Sip of Water Taught Me About Fragile Health Systems
- Carole W. Kamangu
- 5 days ago
- 6 min read
Updated: 2 days ago
At 7 years old, while attending what was considered one of the best private schools in the capital city of Kinshasa in the Democratic Republic of Congo (DRC), I took a sip of tap water and almost died.
No one knew at the time that the water was contaminated until I got ill with a severe amoebic infection that nearly took my life. To a bystander, this was not supposed to happen. After all, in well-equipped organizations like a good school or a state-of-the-art hospital, it is natural to expect things to go smoothly, systems to be organized and to provide an overall sense of safety. However, this was not the case. Even though this school was highly rated, respected and well-equipped with advanced educational tools and health care facilities, it was still part of a larger, fragmented health system. This was my first exposure to system failure, but it influenced my career choice and how I think about health systems and how I work with leaders focused on system strengthening.
A few decades after this experience, in working with senior leaders across healthcare and public health systems, I keep seeing the same pattern repeat itself. It happens in different forms, in different countries and at every level of organizational structure.
The Signals Leaders Usually Misread
In my experience working with healthcare and public health leaders across several countries, the performance issue is rarely the real problem. What often looks like an isolated departmental or individual issue rarely is. However, most leaders I work with arrive at the same conclusion before we ever speak, they believe they have a performance problem. They’re convinced their teams aren’t executing initiatives the way they should or that those initiatives aren’t valid enough to solve their problems. Then they realize that their compliance numbers aren’t improving and their first instinct is to look at what individuals are doing wrong and start to fix the issue there.
The reality is that what leaders see or think is the main problem is only the tip of the iceberg; the visible symptom of something deeper that is threatening the organization’s well-being. Very often, this is what it looks like in many organizations:
Signs of burnout become more obvious across the workforce
Compliance gaps increase despite repeated training or the adoption of the newest technology
Important initiatives are launched with enthusiasm and strong buy-in but fail to scale after piloting
High performers quietly disengage, a phenomenon described as quiet quitting
Most organizations respond to these signals at the surface level by requiring more training, updates in policies and sometimes more oversight.
The big mistake with this approach is that leaders fail to realize that these are not people problems but important signs that something is broken within the system; something that no amount of retraining or personnel change will resolve. What most leaders actually have is limited insight into how the system is operating. Until this is addressed, every performance intervention is just expensive noise.
“The reality is that what leaders see or think is the main problem is only the tip of the iceberg; the visible symptom of something deeper that is threatening the organization’s well-being. Until this is addressed, every performance intervention is just expensive noise.
In conversations and gathering insights from over 260 healthcare and public health leaders, these are the challenges leaders commonly shared:
Policies and strategic priorities often don't match frontline operational realities
Leadership priorities are fragmented and decision-making is siloed
Improvement efforts don’t scale and never produce the long-term benefits they were intended to create
In our recently collected data, 41% of leaders reported that their biggest challenge right now is siloed decision-making. These signals are symptoms of systemic failure that needs to be addressed promptly.
“In our recently collected data, 41% of leaders reported that their biggest challenge right now is siloed decision-making. These signals are symptoms of systemic failure that needs to be addressed promptly.
System Failure is a Silent Killer
Systemic failure doesn’t often happen abruptly. It’s often the result of a culture that has been built up over the years and has become part of the main fabric of the organization’s structure. It’s the result of issues that have been unaddressed for a long time until the consequences have become more obvious and detrimental.
It’s usually seen in behavioral patterns that are often considered to be of little importance. For example, you hear it in the language used in an organization like “We’ve always done it this way”, “That’s not my job," or "I don't know who owns this." This happens long before it's displayed in the data in the form of increased operational costs as a result of a spike in infections, ongoing turnover, and patient (or client) litigation.
When leaders become aware and ready to address these issues, it’s often too late. At this point, they’re not just fixing a problem but also dealing with the costs of having operated on a fragile foundation for a long time. A foundation that affects the long-term revenue and damages the success and reputation of the organization. For leaders who want to prevent these risks from escalating into a crisis, it’s important to create alignment across the organization.
What Actually Changes Outcomes
In our work with senior leaders across healthcare and public health, we’ve seen that real change never starts with accumulating more resources or spending more on shiny objects. It usually starts with leadership alignment both across different levels of leadership and between senior leadership and the frontline.
When leaders agree on a shared priority and redesign the system to support that priority, something different begins to happen. Workflows become efficient, staff engagement improves and compliance becomes part of the culture rather than a mere obligation to meet a benchmark. Over time, staff engagement becomes more tangible and an intentional focus on common organizational goals becomes part of the culture. Then, positive results are seen on leadership dashboards while the system becomes more sustainable.
In one organization, after engaging with executive leaders (i.e. CNOs) and department leaders (i.e. Director of Quality, Director of EVS and Nursing Management), we re-aligned leadership goals with operational realities and redesigned fragmented workflows that improved day-to-day operations. Our actions contributed to over $500,000 in cost savings within a single fiscal quarter. This subsequently led to reductions in infection rates and additional cost savings of over $1million in one fiscal year. The organization’s reputation was elevated into a leader of the industry and subsequently led to its earning of the Magnet recognition.
People didn’t work harder to make these improvements. What leaders did intentionally was focus on the system, identify what was broken and make realistic improvements that produced positive results beyond what was expected.
The Leadership Change Most Organizations Avoid
The hardest shift in mindset for leaders is looking beyond what individuals do and how a small operation can be improved to produce long-term results. The greatest gain is in looking at the entire system and figuring out what small changes will positively affect the organization and lead to long-term results. It's moving from asking "what are our people doing wrong?" to asking "what is this system designed to produce and is it providing what we want?" Every system, without exception, is perfectly designed to deliver its current results. If you don't like the results, you have to look at the design.
This is the conversation most leadership teams avoid because implementing band-aid solutions seems easier and faster. Making sustainable changes requires something more uncomfortable than adding a new initiative or revising a policy. It requires looking at how decisions are made, how priorities are set, how information flows, how leadership priorities are aligned, how leaders and their workforce interact, and being honest about what the system is actually designed to reward versus what leadership says it values.
“This is the conversation most leadership teams avoid because implementing band-aid solutions seems easier and faster. Making sustainable changes requires being honest about what the system is actually designed to reward versus what leadership says it values.
What This Means for You as a Leader
If your organization is experiencing workforce strain despite significant investment, repeated compliance gaps despite continuous training, or improvement initiatives that launch and then quietly disappear, you don't have a performance problem. The problem you’re dealing with is a lack of clarity into what’s really affecting your system design at the source and how your leaders are working together to maintain organizational cohesion. You cannot fix what you cannot clearly see or measure. Most leaders are working with an incomplete picture of where the real misalignment is happening and are making major decisions with partial visibility.
The Strategic Health System Alignment Scorecard™ was built to eliminate that blind spot. It’s a diagnostic tool created to help leaders identify hidden system risks, diagnose misalignment across leadership and operations, and prioritize what actually needs to be redesigned before more time, energy, and resources are spent in the wrong place.
Once you see your entire system clearly, you stop guessing and start fixing what actually leads to long-term results.
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