Redrawing the Arcs in Healthcare: On relationality, systemic design, and the weight of where we place our attention

ARC25 SIGHTLINES | Anthology of Reflexive Contributors

Two years ago, at RSD12, I spoke about the systemic design of healthcare systems drawn from my lived experience in planning the Unified Care Model and transforming large-scale service systems using the Health Systems Transformation Playbook. At the time, I focused on structure and complexity, interdependencies and subsystems, and how to orchestrate transformation not as a heroic act of redesign, but as a slow choreography of continuous storytelling and pathfinding across levels of systems and through time. Since then, one dimension has continuously risen to the surface—more clearly and urgently for me—relationality. Not just the presence of relationships, but the directionality of our relationships, the clarity of what we serve, and the weight of where we place our attention.

In complex systems, everything is connected—but not everything is equally consequential. We design for relationships all the time, often without naming them as such. But which relationships are being designed for? Whose needs are being privileged? Where do we assign our loyalty and our effort—and to what end?

If we are serious about person-centred or human-centred systems, then we must begin by making this North Star explicit, not as a rhetorical device, but as a structural one. The design of any subsystem—clinical, institutional, technological, financial—must ask itself this question: How is this relationship in service of the person, the caregiver, the communities they live in? If the answer is unclear, we are likely designing around ourselves.

And yet, we rarely build systems that begin here, as much as we keep saying that we do or should. The relationship between supply and demand in healthcare remains tilted towards what we can offer, and seldom towards what people truly need. This misalignment is not just conceptual; it is structural, and the systems we have designed are perfectly (or imperfectly) creating inefficiency, frustration, and ultimately waste. We operationalise services, but we don’t always operationalise care and empathy.

To shift this, and for the next iteration of health systems, we must re-anchor our supply systems—our clinical practices, our workforce models, our technologies, our institutions—so that they are structurally and relationally in service to demand-side needs and realities. This is not simply “service orientation.” This is a reconstitution of relationality: from institution-centred to person-centred; from delivery to enablement of people, families and communities.

The forgotten middle: relationality between systems

There is another kind of relationality we fail to design well for—the relationality between subsystems, particularly between microsystems and the mesosystems that should enable them. We pour immense attention into the frontlines: doctors, nurses, and allied health professionals. These are the visible nodes where patients and care meet. We monitor, train, and performance-manage these teams relentlessly. But we forget the system that must exist behind and around them to let them succeed.

This meso-level of data systems, training pipelines, planning functions, technology governance, policy and regulatory levers is rarely visible to the patient and often invisible even to the frontline team. And yet it holds disproportionate power in shaping whether the frontline thrives or flounders. In my experience, much of this power remains dormant; in other words, we spend so much time flogging the horse at the end of the arc that we forget the rest of the system that can work together much more to support and amplify the work of our front-line workers. We do not yet design mesosystems deliberately enough, nor do we value their amplifying potential.

Properly aligned, well-designed and strategically driven mesosystems can radically transform the effectiveness of our microsystems without exhausting their actors. But we must give it clarity of purpose and structural accountability—not to itself, but to the outcomes of those it is meant to serve.

Power, permission, and relational justice

Relationality in complex systems is also deeply shaped by power. Not only in terms of hierarchies—between doctor and administrator, between hospital and community partner—but in terms of whose perspectives are authorised, and whose voices are structurally excluded.

In many conventional systems, medical expertise continues to dominate. And while clinical judgment is essential, it must coexist with other forms of wisdom: lived experience, caregiving insight and community-based ways of knowing, operational knowledge and insights from the rest of the health system. Earlier, I mentioned that many of our mesosystems remain structurally dormant. In my experience, such dormance is learnt and acculturated, often due to the steep difference in power dynamics between front-line staff and back-room departments. When the voices of mesosystems are systematically excluded—whether in design, in governance, or in decision-making—the system becomes relationally lopsided. What could be a chorus becomes a monologue.

The same holds at the boundaries between acute care and what is often dismissively called “step-down care”—nursing homes, community centres, social services. The power asymmetry here is rarely named, but always felt. Acute institutions retain the legitimacy, the resources, and the policy voice. Yet it is the so-called lower-power organisations that walk with patients through the longer, and often harder parts of recovery and adaptation. Relational justice, in this context, means rebalancing how we acknowledge contribution, how we distribute resources, and how we design transition points that are seamless, not just on paper, but in people’s lives.

The arcs we choose to follow

So if there is an “arc of impact” I would want to trace clearer now, it is this: that designing for complexity must always move toward greater clarity of purpose, and greater intentionality in how we relate. Relationality is not soft work. It is the hardest work—because it is the loops between the parts and wholes of systems, it is the love, the power, and the justice in our systems, it is where all meaning, identity and joy are born and therefore, where all transformation becomes possible.

If we want to accelerate the impact of health systems, we must design relationships differently, not just between patients and providers, but between supply and demand, between systems and subsystems, and between people and power. We must acknowledge that the weight of the arc does not lie only at the end point, but across the entire span. And we must be willing to shift our gaze and our effort accordingly.