• Users Online: 298
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2021  |  Volume : 23  |  Issue : 1  |  Page : 75-81

The COVID-19 pandemic and beyond: A systems thinking analysis using iceberg model to transform an organization into a pandemic-resilient institution

Department of Health Services, O/o Directorate General Medical Services (Navy), Government of India, New Delhi, India

Date of Submission08-Dec-2020
Date of Decision30-Dec-2020
Date of Acceptance07-May-2021
Date of Web Publication05-Jul-2021

Correspondence Address:
Dr. Kiran Kumar Maramraj
151/304, Sekhon Vihar, Palam, New Delhi - 110 010
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmms.jmms_183_20

Rights and Permissions

The pandemic continues to be a long-drawn battle with the emergence of new variants of concern of SARS CoV-2 virus and continued challenges of COVID-19 vaccination such as coverage, longevity of protection and real-world vaccine effectiveness against transmission prevention. It is therefore, imperative for every organisation that, it looks beyond the visible impact of pandemic, transform into a COVID-resilient institution and prepare for future threats. We applied systems-thinking approach and used iceberg conceptual model as a tool to evaluate the determinants of pandemic impact on an organisation and to develop a long-term public health strategy. This strategy is a robust four-pronged plan comprising of stringent preventive-cum-mitigation mechanisms in place, efficient health-care facilities, improved habitability and long-term adaptation to new working-norms. The model can be replicated in any organisation which has self-sustainable in-house facilities for accommodation and health care. This strategy comprises of feasible and scientific interventions which can be used to flatten the impact of future outbreaks, epidemics and pandemics of emerging/ re-emerging communicable diseases on functioning of an organisation. The four-pronged strategic interventions plan would serve as a readily available blueprint and better equip the organisations to fight future public health emergencies in an effective manner.

Keywords: Coronavirus disease 2019, iceberg, organization, pandemic, systems thinking

How to cite this article:
Maramraj KK, Roy K, Mookkiah I, Gopinath A. The COVID-19 pandemic and beyond: A systems thinking analysis using iceberg model to transform an organization into a pandemic-resilient institution. J Mar Med Soc 2021;23:75-81

How to cite this URL:
Maramraj KK, Roy K, Mookkiah I, Gopinath A. The COVID-19 pandemic and beyond: A systems thinking analysis using iceberg model to transform an organization into a pandemic-resilient institution. J Mar Med Soc [serial online] 2021 [cited 2021 Dec 3];23:75-81. Available from: https://www.marinemedicalsociety.in/text.asp?2021/23/1/75/320581

  Introduction Top

An organized sector or an organization is one that is incorporated with the appropriate authority, with determined objectives and policies, and follows its rules and regulations. Large-scale organized sectors generally provide in-house facilities to the employees such as accommodation, health-care facilities, and education for children. Organized sectors functioning across the country are either private or state-owned/public sector undertaking organizations including Railways, Armed Forces, Paramilitary Forces, Power, Oil and Gas corporations, and Industries.[1],[2]

The coronavirus disease 2019 (COVID-19) pandemic has altered the functioning of various organizations across the world, and the impact is far reaching. The operational uncertainties and challenges faced by the organizations/organized sectors consequent to evolving COVID-19 crisis have been unprecedented. Since there was no past experience of confronting with such extraordinary situations, there were no readily available blueprints of strategies to comprehensively address these challenges.

Multiple vaccine candidates are currently under trials globally and some of them have sought emergency use authorization from competent authorities for rolling out the mass vaccination. However, several factors such as long-term safety, effectiveness, longevity of protection, availability of cold chain, and accessibility to remote areas determine the achievement of the anticipated herd immunity, and there is a very limited scientific data available in respect of these factors. It is therefore understood that the pandemic would possibly a long-drawn battle with a very gradual tapering off, where pre-COVID normalcy might not be feasible for some time.

It is therefore essential for an organization to transform into a pandemic-resilient institution to effectively deal with the short-term as well as long-term consequences due to evolving pandemic and conduct business as usual during and postpandemic. To achieve such transformation, a long-term comprehensive public health strategy is required to be developed.

Toward this, some organizations made statistical predictions of the disease trends to anticipate the impact of the pandemic. However, such predictions have largely been proved to be futile, as the course of pandemic is deemed to be influenced by multiple factors.[3],[4] Such factors may include viral, environmental, human behavioral, and public health interventions in the community.

The factors that determine the course of pandemic and its impact are thus multifaceted and also interrelated. It is therefore undoubtedly difficult to model real world complexities in an equation. To address this, we conducted a system thinking analysis within the organization using an iceberg conceptual model. The objective of the study was to devise a robust public health strategy with a long-term perspective, for transforming an organization into a pandemic-resilient institution.

  Methods Top

The organization under study is a large, state-owned organized sector with branches widely spread across the country. The organization has in-house facilities of accommodation for employees, educational facilities for children, and hospitals for serving and retired employees along with their dependent family members. We used “system thinking approach“[5],[6] and conducted the study in three broad steps [Figure 1].
Figure 1: Methodology to develop a public health strategy

Click here to view

Step I

We identified the events which reflected the visual impact of the COVID-19 pandemic on organization from March 01 to November 30, 2020 [Figure 2]. We built a three-tier conceptual iceberg model to assess various factors associated with the impact of the pandemic on the organization, as it evolved. Level 1 of the model represents the tip of iceberg which is a noticeable impact in terms of morbidity and mortality in the community. Level 2 specifies the patterns exemplified by events of impact and Level 3 represents the organizational structures and behavioral attributes of the employees which are the underlying root-causes that directly or indirectly influence the degree of impact on the organization [Figure 3]. This was evaluated independently by two groups and then discussed to prepare a unified model.
Figure 2: Visible impact of pandemic on organization

Click here to view
Figure 3: Iceberg conceptual model

Click here to view

Step II

Based on the findings of Step I, we further identified the leverage points of intervention at all three levels of iceberg [Figure 3]. The leverage points were selected with a view that even a small change at that level should have substantial effects in positive outcome. Postindependent analysis, the discussions were consultative, and in situation of no agreement, the view of the majority was endorsed.

Step III

We then formulated a comprehensive public health strategy, aligning all the identified leverage points with actionable components, for on-ground implementation by the organization [Figure 4]. As part of external audit, the strategy devised based on the model built was also vetted by a domain expert who was not part of the model building.
Figure 4: Four-pronged public health strategy

Click here to view

  Results Top

Step I: Evaluation of pandemic impact and its determinants using iceberg model

Level 1 of Iceberg conceptual model (visible impact)

Assessment of noticeable impact of pandemic on the organization revealed that the it was primarily on community health, operational aspects of the organization, and health-care system. With first laboratory, COVID-19-positive case reported in April 2020, the organization eventually witnessed a total of 3148 cases (2.4%) until November 30, 2020. Out of 3148 laboratory-positive cases, 2854 were employees (3.6%) and 294 were reported among the families of employees (0.6%). One employee died due to COVID-19 and eight deaths were reported among families. Among the retired employees and their families, a total of 433 cases (1.3%) and 61 deaths were reported. Out of total 122 deaths reported by hospitals of the organization, 108 (89%) had at least one comorbidity such as heart disease, diabetes, hypertension, bronchial asthma, and lung disease. The mean age of fatal cases was 64.5 years.

Country-wide lockdown gave time to build up strategic resources and ensured capacity building of hospitals in terms of preparation of guidelines, earmarking role and training of hospital employees, procurement of equipment, and implementation of infection control procedures. However, obtaining consumable and nonconsumable items and sky rocketing prices of medical stores were also a challenge faced during the initial phase of lockdown. Inability of hired contractual staff to report for duty overburdened the existing hospital staff. Creation of screening centers, isolation, and quarantine facilities at various places drained the scanty resources. The impact on operational aspects of the organization and health-care system is elaborated in Figures 2 and 3.

Level 2 of Iceberg conceptual model (epidemiological patterns)

The unique patterns of the visible impact during the study period are given in Figure 3. During April to mid-June 2020, cases from the organization across the country were largely sporadic in nature and limited to only one station which was co-located with a metropolitan city. The stations which were reported to be initially affected were largely co-located with the metropolitan cities and followed the similar pattern of urban-based incidence trends in the country. However, as the pandemic evolved from June to November 2020, cases were also reported from other stations located at semi-urban and remote areas.

Clusters of cases were reported in quarantine facilities and men's hostels in six out of 12 stations (50%) during postlockdown period (June–July 20), when large number of employees reported back and re-joined duty from outstation leave/duty. Clusters of cases were also reported among security personnel who guard the entry points of offices and health-care workers (HCWs) of hospitals.

The employees reporting back from outstation leave/duty and married employees not residing in company quarters were identified as potential importers of infection into the community. When company offices are co-located with urban areas and employees are compelled to stay in areas outside the community due to shortage of accommodation, they become vulnerable for the communicable diseases.

Level 3A of Iceberg conceptual mode (organizational structures) [Figure 3]

Habitability is one of the important structural challenges toward interruption of viral transmission in a closed setting. Space constraints in quarters for unmarried employees made it difficult for the employees to comply with physical distancing norms. The deficiency of accommodation/quarters for married employees resulted in either sharing of company quarters or hiring of accommodation in areas outside the community. Space constrains in most office spaces also resulted in sporadic outbreaks in these areas.

Mandatory periodic induction of employees across the country, their continuous training, and frequent outstation movement on duties/leave are peculiar and inherent features of the organizational functioning, which influenced the impact of pandemic on the organization.

Level 3B of Iceberg conceptual model (behavioral aspects) [Figure 3].

Despite certain structural constraints, the disciplined lifestyle and self-regulation of the employees possibly enabled the organization to minimize the impact of the COVID-19 pandemic. This behavioral pattern has reflected strict assurance of implementation of public health strategies and protocols to prevent and control the infection. Honest and early reporting of illness by the employees resulted in early isolation and interruption of viral transmission. However, “Infodemic,” conflicting messages in social media and changing guidelines created a sense of uncertainty. Extensive movement restrictions and prolonged quarantine of individuals in key operational sectors resulted in mental stress among some of these individuals. The human resource (HR) management system in the organization ensured continuous two-way communication between the employees in an institutionalized manner. A systematic approach through unit-level surveillance and risk communication mechanisms addressed most of these issues.

Step II: Identifying leverage points of intervention

We identified leverage points of intervention at different levels, in order to address the impact of pandemic and its determinants [Figure 3]. These leverage points were intended to mitigate the acute effects of pandemic due to viral transmission in the community, to restore the normalcy in providing health-care services and conduct of routine business within the ambit of COVID-19 restrictions. Some of the interventions are long term in nature and envisioned to make the community self-reliant.

Step III: Developing a public health strategy for transforming an organization into a pandemic-resilient institution

Based on the findings from Step I to II, we developed a four-pronged comprehensive public health strategy [Figure 4] for implementation by the organization to transform it into pandemic-resilient institution. The details of the strategic interventions are given in [Table 1].
Table 1: A comprehensive Four-Pronged Public Health Strategy to Transform an Organisation into Pandemic-Resilient Institution

Click here to view

  Discussion Top

System thinking approach and iceberg conceptual model

Systems thinking approach provides a broad outline to look beyond the infection transmission and better appreciate the multiple interconnected factors associated with infection control. It helps public health policymakers to build programs and policies that are prepared for unintended consequences.[7],[8] Michael Goodman has designed the iceberg model and used it as a systems-thinking tool to evaluate the patterns of behavior, supporting structures, and mental models that underlie a particular event.[9] We applied this model to evaluate the determinants of pandemic impact on an organization. This iceberg model is different from the iceberg phenomenon which is widely used in public health sector to describe the link between clinical epidemiology (symptomatic cases) and population-based epidemiology (asymptomatic/subclinical cases).[10]

When tip of the iceberg is managed as a knee-jerk response, it is expected that the buoyancy of the ice below the sea level would simply push up to re-form the tip again. The iceberg model helps to exemplify that the impact of pandemic is to be addressed in a long-term manner and therefore, making necessary modifications in structures and influencing behavior models has a more far-reaching effect than firefighting the discrete events of visible impact. The Iceberg model helps the individuals and organization to expand the insight of circumstances to see it within the context of the whole system and not limit themselves to looking at noticeable impact.

Impact on health status of community: Underlying determinants and strategic interventions

By end November 2020, while global COVID-19 cases crossed 61 million[11] and national figures surged past 9 million,[12] cases among the employees in the organization under study has remained under 3000 mark, possibly attributed to their disciplined and self-regulated lifestyle of employees, strict implementation of basic preventive measures, and robust HRs management system.

Individuals residing in closed settings are more vulnerable for clusters/outbreaks.[13] In the current study, employees residing in men's hostel were identified as vulnerable group due to closed settings and space constraints. Occupational vulnerability to infection has been well established among HCWs.[14] In the present study, health-care workers in hospitals and security personnel guarding the entry points were more vulnerable due to higher degree of exposure both in terms of frequency and duration. Several studies reported vulnerability of COVID-19 patients to mortality due to age and comorbidities.[15],[16],[17],[18] In the current study, the mortality was primarily reported among retired employees and their dependents with at least one co-morbidity. During initial months (April–July 20), it was evident that the infection was possibly imported by the individuals residing in containment zones outside the community and by those who travelled outstation on duty/leave.

Thus, the two most important underlying determinants of impact of pandemic on health status of community were movement of employees and space constraints in living and working environment. Restriction of movements of employees, safety precautions while travelling, entry and exit surveillance,[19] quarantine of travellers, protection of vulnerable groups, and addressing underlying issues of habitability (shortfalls in accommodation) were the recommended strategic public health interventions to minimize the adverse impact on health status of the community [Table 1].

Impact on operational aspects of the organization: Underlying determinants and strategic interventions

The operational aspects of the organization adversely affected by the pandemic were induction of employees, their training and outstation movement on duty, and maintenance of operational units of the organization. The impact on operations was maximum in those stations which are in close proximity to the urban areas or co-located with cities, and during the periods of lockdown/immediate postlockdown.

The basic epidemiological pattern of the COVID-19 pandemic has been essentially an urban phenomenon during the initial study period (April–May 2020). The virus had its origin in a Chinese city of Wuhan and spread quickly to other cities of the world.[20] In India, the “epicenters” of the coronavirus outbreaks until May 2020, according to the health ministry's data, have been largely urban areas with over 75% of the total number of positive cases reported from the top 35 urban agglomerations, with 13 metropolitan cities.[21] Higher population density with urban poor settlements and relatively high international/domestic travel possibly make the urban areas more prone.

A gradual shift from urban-exclusive pattern to a mixed pattern was witnessed as the pandemic evolved. The country reported clusters in sub-urban areas and rural areas due to mass movement of migrant laborers postlockdown.[22],[23] In the similar lines, sporadic cases and small clusters were reported by some remote stations of the organization in the current study when large number of employees reported back from outstation leave/duty, especially during postlockdown period.

Thus, the two most important underlying determinants of impact of pandemic on operational aspects of the organization were the location and self-reliance of the communities, and ability to maintain the key operational units of the organization free from infection. For the later aspect, COVID-19 Social-Bubble strategy was recommended, where individuals working in key operational sectors and front-line workers are subjected to reverse quarantine and restriction of movement to protect themselves from the rest of the community.[24],[25] Quickly adapting to the new working was one of the key recommended public health measures to deal with the pandemic and beyond [Table 1].

Impact on health-care facilities: Underlying determinants and strategic interventions

As the pandemic evolved, Health-Care Facilities (HCFs) faced different challenges in terms of increased patient load, increased demand of medical equipment and stores, and HR management of all the front-line workers in hospitals. Rotational duty rosters, quarantine schedules, reallocation of HCWs in respective hospital zones, and mental health of HCWs were important challenges faced by HCFs.

Decongestion and strengthening of HCFs were an extremely important exercise in high COVID-19 transmission areas. It was imperative for HCFs to decentralize nonessential medical services, earmark flu-screening clinics, strengthen laboratory services, and enhance the procurement of medical stores including personal protective equipment and implement measures to protect the HCW workforce in a sustainable manner. As a long-term measure, design for the future hospitals needs to be reworked with a focused approach toward the prevention of cross-infection in hospitals [Table 1].

  Conclusion Top

Considering various challenges of COVID-19 vaccination such as long-term safety, effectiveness, longevity of protection, availability of cold chain, and accessibility to remote areas, the pandemic would possibly a long-drawn battle with a very gradual tapering off and therefore it is imperative that we look beyond the visible impact of pandemic, transform the organization into a COVID-resilient institution, and prepare for future threats. We applied systems-thinking approach and used iceberg conceptual model as a tool to evaluate the determinants of pandemic impact on an organization and to develop public health strategy. This strategy is a robust four-pronged plan comprising stringent preventive-cum-mitigation mechanisms in place, efficient HCFs, improved habitability, and early adaptation to new working-norms. The model can be replicated in other organizations which have self-sustainable in-house facilities for accommodation and health care. This strategy comprises feasible and scientific interventions which can be used to flatten the impact of future outbreaks, epidemics, and pandemics of emerging/re-emerging communicable diseases on functioning of an organization. The four-pronged strategic interventions plan would serve as a readily available blueprint and better equip the organizations to fight future public health emergencies in an effective manner.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Suzan H. Employment in India's organised sector. JSTOR 1991;19:7.  Back to cited text no. 1
Government of India, Ministry of Labour and Employment. Available from: https://labour.gov.in/. [Last accessed on 2020 Aug 22].  Back to cited text no. 2
Ferguson NM, Laydon D, Nedjati-Gilani G, Imai N, Ainslie K, Baguelin M, et al. Impact of Non-Pharmaceutical Interventions (NPIs) to Reduce COVID-19 Mortality and Healthcare Demand. Available from: https://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/Imperial-College-COVID19-NPI-modelling-16-03-2020.pdf. [Last accessed on 2020 Sep 06].  Back to cited text no. 3
Bhatia R, Abraham P. Lessons learnt during the first 100 days of COVID-19 pandemic in India. Indian J Med Res 2020;151:387-91.  Back to cited text no. 4
[PUBMED]  [Full text]  
Carey G, Malbon E, Carey N, Joyce A, Crammond B, Carey A, et al. Systems science and systems thinking for public health: A systematic review of the field. BMJ Open 2015;5:e009002.  Back to cited text no. 5
de Savigny D, Adam T. Systems Thinking for Health Systems Strengthening. Geneva: Alliance for Health Policy and Systems Research, World Health Organization; 2009. Available from: https://www.who.int/alliance-hpsr/systemsthinkinghss/en/. [Last accessed on 2020 Oct 30].  Back to cited text no. 6
Xia S, Zhou XN, Liu J. Systems thinking in combating infectious diseases. Infect Dis Poverty 2017;6:144.  Back to cited text no. 7
Leischow SJ, Best A, Trochim WM, Clark PI, Gallagher RS, Marcus SE, et al. Systems thinking to improve the public's health. Am J Prev Med 2008;35 (Suppl):S196-203.  Back to cited text no. 8
Goodman M. The Iceberg Model. Hopkinton, MA: Innovation Associates Organizational Learning; 2002. Available from: http://www.ascd.org/ASCD/pdf/journals/ed_lead/el200910_kohm_iceberg.pdf. [Last accessed on 2020 Nov 16].  Back to cited text no. 9
Last JM. The iceberg revisited. Int J Epidemiol 2013;42:1615-7.  Back to cited text no. 10
World Health Organisation. Coronavirus Disease (COVID-19) Dashboard. Available from: https://covid19.who.int/. [Last accessed on 2020 Sep 15].  Back to cited text no. 11
COVID-19 India. Ministry of Health and Family Welfare, Government of India. Available from: https://www.mohfw.gov.in/. [Last accessed on 2020 Sep 15].  Back to cited text no. 12
World Health Organisation. Coronavirus Disease (COVID-19) News Room Update. Available from: https://www.who.int/news-room/detail/13-05-2020-unodc-who-unaids-and-ohchr-joint-statement-on-covid-19-in-prisons-and-other-closed-settings. [Last accessed on 2020 Sep 15].  Back to cited text no. 13
Nguyen LH, Drew DA, Graham MS, Joshi AD, Guo CG, Ma W, et al. Risk of COVID-19 among front-line health-care workers and the general community: A prospective cohort study. Lancet Public Health 2020;5:e475-83.  Back to cited text no. 14
Sanyaolu A, Okorie C, Marinkovic A, Patidar R, Younis K, Desai P, et al. Comorbidity and its Impact on Patients with COVID-19. SN Compr Clin Med 2020;25:1-8.  Back to cited text no. 15
Leung C. Risk factors for predicting mortality in elderly patients with COVID-19: A review of clinical data in China. Mech Ageing Dev 2020;188:111255.  Back to cited text no. 16
Yang J, Zheng Y, Gou X, Pu K, Chen Z, Guo Q, et al. Prevalence of comorbidities in the novel Wuhan coronavirus (COVID-19) infection: A systematic review and meta-analysis. Int J Infect Dis 2020;94:91-5.  Back to cited text no. 17
Bhandari S, Bhargava A, Sharma S, Keshwani P, Sharma R, Banerjee S, et al. Clinical profile of COVID-19 infected patients admitted in a tertiary care hospital in North India. J Assoc Physicians India 2020;68:13-7.  Back to cited text no. 18
World Health Organisation. Coronavirus Disease (COVID-19) Newsroom Update. Available from: https://www.who.int/news-room/articles-detail/public-health-considerations-while-resuming-international-travel. [Last accessed on 2020 Sep 15].  Back to cited text no. 19
Sundararaman T. Health systems preparedness for COVID-19 pandemic. Indian J Public Health 2020;64 Suppl S2:91-3.  Back to cited text no. 20
Zhu H, Wei L, Niu P. The novel coronavirus outbreak in Wuhan, China. Glob Health Res Policy 2020;5:6.  Back to cited text no. 21
Leng T, White C, Hilton J, Kucharski A, Pellis L, Stage H, et al. The effectiveness of social bubbles as part of a COVID-19 lockdown exit strategy, a modelling study. Wellcome Open Res 2021;5:213.  Back to cited text no. 24
Sharun K, Tiwari R, Natesan S, Yatoo MI, Malik YS, Dhama K. International travel during the COVID-19 pandemic: Implications and risks associated with 'Travel Bubbles'. J Travel Med 2020;27:taaa184.  Back to cited text no. 25


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1]


Similar in PUBMED
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Article Figures
Article Tables

 Article Access Statistics
    PDF Downloaded91    
    Comments [Add]    

Recommend this journal