Innovating to Address the Systemic Drivers of Health

Illustration by iStock/mathisworks

In a community just a few miles from the headquarters of Google, Apple, and Tesla, a young woman, we will call her Elisa, lives with her kids in a small apartment. Each day, Elisa takes two buses and 70 minutes to get to work. Her kids walk to and from school, down the street from their home. Her over-built community only has a few trees, and cars speed by on the main road to get to meetings across Silicon Valley. The air in her community is polluted, with local chronic obstructive pulmonary disease (COPD) rates rising. She also lives in a food desert, which makes getting nutritious and affordable food difficult. The nearest fresh food grocer is three miles away, across the 101 freeway. The corner store by her house primarily sells alcohol and snacks. 

Each month, most of Elisa’s salary is spent on rent. She can afford one big shopping trip in the month and at the end of the month she visits the local food pantry to subsidize until she gets her next paycheck. Elisa suffers from high blood pressure and is therefore two to three times more likely to get diabetes. Her lack of access to healthy food, along with the stress associated with getting food and making ends meet, exacerbates her risk. Unfortunately, there are not many health clinics nearby where Elisa can get easy access to primary care with her Medicaid insurance. Over the last year, she had to visit the emergency room at the local hospital three times when she and members of her family developed severe respiratory symptoms.

Elisa isn’t alone. There are communities like hers all over America. Life expectancy can differ up to 30 years in the US between different zip codes in the same state, indicating the significance of socioeconomic, environmental, and social factors in driving health outcomes. Globally, the disparities in health care outcomes between different countries; between rich and poor; between insured, underinsured, and uninsured; and between white, Black, Latino, Asian, and others are dramatic. Yet, in our siloed and disease focused healthcare systems, the root causes for poor health and disparities go largely ignored. The current approach to health has resulted in poor outcomes despite very large investments in health care and health innovation ecosystems. For example, the top 10 countries in “health care innovation” as measured by the FREOPPS World Index of Health Care Innovation, are countries where health care costs are skyrocketing and communities still have moderate to poor health outcomes, along with growing chronic disease rates.

 

Life expectancy in the US has lagged behind other countries despite more spending in the health care system. Source: Our World in Data

Today our health care innovations are mostly focused on development of new diagnostics, therapeutics, and administrative solutions to improve health care delivery. While these solutions are important and advance every year, public health is increasingly challenged by factors that are outside what we traditionally define as the health care sector.

How can health innovations help people like Elisa whose health is dramatically impacted by factors like clean air, healthy food, a safe home, and access to health care, education, and a job that can sustain her family? Historically, the Social Determinants of Health (SDoH) has been used as a term to capture these important upstream, non-medical drivers of health. These factors, while believed to have the biggest impact on health outcomes, have largely been assumed to be the responsibility of the public sector and have mainly stayed out of the focus of the health care system.

Today, we are witnessing even more impactful phenomena than what SDoH was originally defined to capture, which warrants a more expansive definition. Research shows that health outcomes are not only impacted by the immediate social and environmental context of the individual but by a complex set of interconnected factors and global systems well beyond the individual's control and influence. We call these factors the Systemic Drivers of Health.

The Systemic Drivers of Health are the nested and interconnected sets of local and global factors that have significant impact on population and individual health outcomes. Systemic Drivers of Health extend beyond traditional health care (e.g. hospitals and clinics) and the individual’s immediate situation to include the behavioral, social, environmental, and structural factors that can have a direct impact on their overall health. In order to truly understand these factors, innovators need to examine the root cause drivers of our health challenges. Only once these root cause drivers are addressed will we be able to meet today’s complex health care needs and rising costs.

The Systemic Drivers of Health

 

A model of the Systemic Drivers of Health with examples of behavioral, social, environmental, and structural factors. Image by the authors.

Our proposed model of Systemic Drivers of Health expands the current SDoH framework by adding:

1. Global perspective and interconnectedness: While the current SDoH definitions focus more on the individual’s immediate context, we expand the model to take into account today’s globalized and interconnected world. This breadth may seem unnecessary—that is, it may seem that optimizing systems locally (at the person, group, or population level) would naturally aggregate to larger scales. However, there is abundant evidence that addressing interconnected global factors is necessary. One example is human activity causing climate change and contributing to poor health outcomes (e.g. through water insecurity, mental health crises after climate disasters, increase in respiratory and cardiovascular disease from poor air quality due to wildfires). Behavior in one area impacts the health of humans and their environment at large distances. Another example is the impact of misinformation, often created by content creators geographically remote from consumers, that then can influence behaviors like vaccine hesitancy or a lack of trust in health care providers. Governments and their policies in far off places can affect food supply or the spread of disease at home and can go further to impact elections, social policy, and even violent conflicts with loss of life. The rapid pace of technology development, globalization, population growth, and business practices have created a web of interconnected factors that requires us to rethink our approach to solving and innovating for health problems.

2. Multi-level investigation: We purposely nest the circles that describe the drivers of societal health because when innovators investigate problems they must do so on multiple levels and across stakeholders and problem areas. We see this framework as a tool for innovators to use to conduct research and to probe for better understanding of problems. The outer levels have a higher impact on population health outcomes than the inner layers, creating an ordering of factors to investigate as intervention points for improving a particular health outcome.

3. Factor interdependency and breaking the silos: While previous models presented a list of important factors that drive health outcomes, we are highlighting the important relationships and interplay between behavioral, social, environmental, and structural factors that need to be considered in developing plausible solutions. For example, a solution to help Elisa manage her diabetes might not work in her community because of the cultural or economic barriers that are present.

4. Poor, rich, and everything in between: SDoH is typically used to illustrate poor health outcomes for underserved communities. Today, we observe phenomena with much broader reach. For example, we see many wealthy countries with an increased burden of chronic illnesses like metabolic disease, often as a result of changing diet and more sedentary work that is typical in higher income countries. At the same time, climate change and the associated disasters are a large contributor to climate anxiety and other health issues that broadly affect both the rich and poor.

There is plenty of evidence that these factors play a critical role in impacting population and individual health outcomes, yet our current health care system and therefore the innovation sector around it today has evolved to be largely reductionist, individualistic, reactive, and inequitable. Traditional medical innovators are typically focused on the surface-level challenges related to health care delivery. If we are to aspire to a paradigm shift towards a more systemic, societal, preventive, and inclusive healthcare system, there is a true need to dig deeper and look at the Systemic Drivers of Health as an opportunity for innovation.

A Call for Entrepreneurship

Many entrepreneurs choose health care as a venue for innovation because it is one of the sectors where one can do well by doing good. However, the majority of entrepreneurship in the health sector has focused on downstream interventions such as therapeutics and health delivery solutions. Closing the gaps on health care outcomes and attending to societal health needs, meanwhile, has mostly been assumed to be the responsibility of the public and nonprofit sectors, leaving the market with few effective solutions. While philanthropy and policy work continue to play a very important role in mobilizing more energy towards these issues, we ultimately need innovators and entrepreneurs to build and scale new solutions.

Entrepreneurs are uniquely positioned to make a difference in societal health outcomes: They can develop technology and science-based solutions, scale innovations through profitable business models, attract talent and capital to grow their solutions, and leverage market forces for impact. With global health care costs reaching $10 trillion a year and health care disparities remaining high, entrepreneurs have great opportunities for impact and financial return if they turn their attention to the Systemic Drivers of Health.

There are some early signs of success from entrepreneurs going after the root causes of our health challenges. The following inspiring examples illustrate how entrepreneurs who push to address the many systemic drivers of health that Elisa and others like her experience are having an impact. These founders go beyond existing health care business models with cross-sector collaborations and more innovative and patient approaches to financing.

In Georgia, families like Elisa’s don’t have to go to bed hungry but instead get easy access to healthy food, near their home, while the community as a whole wastes less food, because of Goodr, a food logistics software company. Using Goodr, large and small organizations including food manufacturers can easily manage the logistics and tax write-off process of donating excess food to families who need it. Goodr completes thousands of deliveries per week, often with over 500 healthy meals per delivery. For one client they have reduced waste by 47%, diverting 157,670 pounds of food from the landfill while helping concessionaires claim $200K in tax benefits in six months.

Unite Us, a technology company founded in 2013, coordinates care networks and connects health and social service providers together to efficiently deliver care and services to families who would normally struggle to access them. Instead of navigating individual services across the community when needs arise, Unite Us makes it easy for families like Elisa’s to access the services they seek and receive them efficiently from a connected ecosystem. Today, Unite Us helps 33 million Americans receive better care through software-enabled collaboration between services ranging from traditional health care to housing and shelter.

Living in food and resource deserts makes it hard for underserved communities to access health care supplies and food. Zipline changes this. Zipline has built the world's fastest and most reliable drone and delivery service and operates globally delivering critical health supplies to individuals and health care providers on-demand. Increasing access to vaccinations, blood, and other medical supplies; employing people locally to fly and manage drones; and reducing carbon emissions from other delivery methods makes Zipline’s approach unique. Studies and evaluations show Zipline has been able to reduce maternal deaths from postpartum hemorrhaging, increase vaccination rates, and get food to hard to reach communities, while reducing gas powered emissions by 97%.

Lack of access to education can make the difference between good and poor health. But low literacy rates in impoverished communities like Elisa’s and all over the world impede a person’s ability to access health care and get work. Amplio, a nonprofit organization founded in 2007, uses technology and social behavior change communication to impact the world’s hardest-to-reach communities through culturally sensitive and language appropriate talking books that scale the delivery of education and information to hard to reach communities. Amplio has impacted over two million people in low-literate communities across 14 countries, with a focus on women and girls.

Looking Ahead

These are just a few examples of social impact businesses that address some of the Systemic Drivers of Health, but this space is still in its infancy. To solve the health challenges of the 21st century, we need an urgent revision and expansion of our health innovation ecosystem.

Given the astronomical cost of health care and the potential to solve many of these problems through innovation, entrepreneurs and investors who turn their attention to the Systemic Drivers of Health have the opportunity to create impactful and profitable businesses that can truly drive change. But shifting the entrepreneurship ecosystem in this way will require rethinking entrepreneurship education, culture, and investment practices. Formalizing the innovation opportunities and systematically identifying unmet needs and solution areas is what will inspire, attract, and enable more innovators to focus on improving health outcomes. The ultimate result will be a new health innovation ecosystem that is more preventive and inclusive.

Read more stories by Narges Baniasadi, Michelle de Haaff & Pedram Afshar.