A Health System
Built on Racial Equity

Section 02

What is the health system we have?

“We all are actors in this process, and carry water for these systems that harm us and exclude us.”

– Theresa Trujillo, project Advisory Team member

No system, whether it’s a system of education, agriculture, or health, exists in isolation. Each of these systems is deeply embedded in the cultural, political, and economic context of our country. As is shared across this analysis, researchers found that the design of the health system reflects a set of dominant beliefs in our society, in particular:

1. A hierarchy of human value. While few Americans would publicly identify as racist, there is a persistent implicit belief in U.S. society that some lives matter more than others. As one leader noted, “The underlying belief that some groups of people are superior to others is baked into medicine and healthcare and nursing…When people devalue others, they find ways to turn those tools and measures into racist tools and measures.”
   
   This hierarchy of human value doesn’t just determine who gets a kidney transplant or ventilator, but who gets access to the full range of health drivers, including quality housing, food, and education. And in the culture of healthcare itself, this hierarchy extends daily into choices and policies about who gets what jobs and whose voices are heard, or not, in meetings.
2. An embrace of individualism. If you’re not healthy in this country, the system and those within it will tend to blame you as an individual for the “choices that you’ve made” that have led to your health situation. Even lack of access to care reflects this bias: “When we choose not to help people, we’re ultimately blaming them for their choices,” one leader noted. 
   
   This individualistic focus shows up in the sector’s emphasis on “lifestyle factors” or “behavioral health” rather than naming the social, political, and economic drivers of those choices. While individual responsibility is of course one key to good health over time, this belief that health and wealth are primarily determined by individual choices and behaviors is pervasive across our society, and is especially harmful in our health system. 
3. An assumption of scarcity. The “zero-sum game,” the basic belief that if some are going to do well that others have to do worse, supports how the hierarchy of human value plays out in terms of access to resources, supports, and opportunities to improve one’s health and wealth.  As one leader noted, “we have an enormous amount that we can, and should, do something with” to make a health system that can work for everyone.
4. A foundation of capitalism. The healthcare system is increasingly adopting a capitalist mindset.  There is growing privatization of care, and a greater focus on building wealth through billion-dollar capital campaigns that allow even nonprofit health systems to hold hundreds of millions of dollars in assets.  Health systems rationalize fundraising in the name of ensuring quality of care over time through financial security, while simultaneously denying equitable access to that care to those who need it most.

The combination of these beliefs form the basis of a harmful, self-reinforcing dynamic: 

1. Our political, economic, and health systems have been designed to help some people do better (especially those who are white with financial wealth); 
2. These systems are accepted as “objectively-given” and not human-designed and created over time;
3. If those who are better off earned their success, and if our health system benefits those people more than others, that is only fair;
4. On the other hand, if people are not doing well, it’s their own fault and it’s just not possible for us all to be successful anyway, so it’s better to just stick with the systems we have.

These beliefs have convinced us to accept a national health system in which healthcare providers make more money when people are sicker, where BIPOC people are systematically sicker and dying faster based solely on the social construct of race, and where people hold little hope of changing the system despite few people being satisfied with how it operates.

To more clearly convey how the health system operates, CoCreative synthesized insights from health leaders to develop maps that depict how health equity is undermined by societal beliefs. The maps were reviewed and refined by the project’s Advisory Team.

Given the mutual interdependence of these driving beliefs and the realities of our current health system, we must realistically talk about changing both our health system and the context in which it operates? Otherwise, any efforts to change our health system will be undermined by the larger political, social, and economic context in which it operates. 

Our health system is both economically influential and plays a unique role within our society, making it a powerful platform for larger societal change. By grounding our health system in its purpose of care, health, and wellbeing, we collectively have a powerful leverage point for shifting the larger culture and the systems that support health. The health system is full of caring, compassionate people who want good health for themselves and others. It also has resources which, although unevenly distributed and heavily concentrated in healthcare in particular, are nearly unparalleled in our economy. The many people we consulted believed that the health system can lead, model, and create a vision of what’s possible and show the way to a more equitable, just, and healthy society. 

Structural Racism in the U.S. Health System

To ground this inquiry in the lived experiences of people within and around the health system, CoCreative conducted 61 in-depth interviews with health system stakeholders, both those who are in positions to most impact health outcomes and those who are most impacted by disparate outcomes based on race.

There were also six open consultation sessions with an additional 150 health system stakeholders and patients. Additionally, a six-person Advisory Team reviewed and helped deepen and extend the structural analysis. The following 10 key themes emerged from this consultation process. Learn more about the consultation methodology.

How Structural Racism Drives Health Disparities

With racial equity a more urgent national priority, the Robert Wood Johnson Foundation wanted to hear from leaders about what it would take to dismantle structural racism in the health system . And, how we could create a better system, grounded in equity, that works better for everyone.

More than 200 health leaders spoke to these questions through an 8-month collaborative process led by CoCreative. To more clearly explain how racism fuels health disparities, CoCreative synthesized the insights of health leaders and developed this map.

Let’s start with access to resources. Good health is closely connected to where we live. Research has shown that we enjoy longer, healthier lives when we have access to the drivers of good health, like quality housing, healthy food, good schools, and reliable transportation.

But in the U.S., access to quality resources like safe housing largely depends on a person’s earning power. Without good-paying jobs, people have less income and wealth, and can’t afford to live in resource-rich neighborhoods.

Likewise, lower access to these resources also determines people’s earning power. This dynamic forms a vicious, self-reinforcing cycle that has undermined health and opportunity for lower-income families for generations.

But it’s not only about economics. For decades, for example, redlining and housing segregation have kept people of color out of well-resourced neighborhoods. Too often, people of color can only afford to live in communities with unsafe housing, under-invested schools, poor quality healthcare, and few fresh food options.

There’s a long history of denying people of color equitable access to resources and opportunities, starting with the extraction of wealth and land from indigenous people and continuing to slavery. That legacy of racism shows up today in job discrimination, lack of capital for BIPOC-owned businesses, the system of mass incarceration that disproportionately targets and harms people of color, and in many other areas.

And these factors impact not just one generation, but multiple generations, also showing up as intergenerational disadvantage and trauma that’s associated with poorer health and shorter lives for people of color.

The health care system has reinforced these cycles. Institutional investment policies, hiring practices, and procurement policies that drive and reinforce gentrification, low-wage jobs, and concentration of wealth in white communities deepen the impacts of structural racism. At the same time, some health systems are now starting to leverage their economic assets as positive forces to address racial disparities, a powerful force for equity given that health care is so economically powerful, employing 11% of American workers and accounting for 24% of government spending.

Health care, however, is also dominated by white administrators and doctors who are trained in medical schools that reinforce racist beliefs and practices. Racism in medical admissions and educational access is another barrier that results in the health workforce not mirroring the communities they serve.

And when people of color receive worse care because doctors are biased, or make flawed assessments due to racist diagnostic tools, it’s easy to understand why BIPOC have lost trust in the health system, making it less likely they will participate in clinical trials or trust new or existing medical treatments, therefore worsening health outcomes.

As we look at the big picture, all of these dynamics work together to undermine the health and well-being of people of color and other systematically disadvantaged people.

These dynamics do not only impact people of color, however, because many of the solutions to improve these dynamics will also support better health for all Americans. Take the example of curb cuts. Because street corners used to have curbs that made it difficult for people with disabilities to move between sidewalks and crosswalks, disability activists created and then fought for curb cuts. It soon became clear, however, that so many more people benefit from this solution, like people using strollers, skateboarders, people who have trouble with their legs, or people using carts to carry groceries home. So if we design our health system to include and take care of the widest diversity of people, then we all benefit.

Section 03

Where is Change Most Needed?

“Disparities don’t naturally grow on trees. They don’t naturally appear in nature…Anything that’s been socially constructed can be socially deconstructed.”

– Michellene Davis, project Advisory Team member

The kinds of structural change most needed

The research team asked leaders across the health system to identify the most critical shifts needed to move toward the vision they had expressed for equitable health in this country: 

A racially just and equitable health system grounded in love and belonging that treats people with dignity, provides culturally excellent high-quality care, and enhances the well-being and quality of life for all people. 

The shifts below attempt to synthesize the feedback from these health leaders on the “problem spaces” where they believe health system leaders might focus their efforts for greatest impact. They are not about HOW to create change but WHAT PARTS of the system most need to change in order to make the vision a reality. Most importantly for this inquiry, these shifts have informed researchers about the kind of leadership the health system really needs, and where. As you review the shifts, you may get a sense that they imply a different level of leadership (beyond institutional-level change), more diverse leadership, and different ways of approaching change across organizational and sectoral boundaries than has been employed in the past.

Some of these shifts may seem daunting and reasonably raise skepticism. The research did not specifically look at what is feasible at this point, because feasibility often leads to transactional, marginal, and short-sighted interventions. Instead, we wanted to know what leaders identified as aspects of this system that most need to change, no matter how difficult the change or how long that change might take. Some shifts may take years, while others will take generations. This is the nature of the structural change that is required to achieve the vision.

Finally, this list of the 14 most-needed structural shifts is shared with the caveat that, while this research project is finished, the learning and evolution of our research team’s thinking is not. This set of shifts will necessarily evolve as the work continues to deepen a shared understanding of where the most powerful opportunities for structural change in our health system lie. 

Structural Shifts to Achieve Racial Equity in the U.S. Health System

The imperative to evolve our approach to leadership

If there is one overriding theme that emerged from this consultation process, it’s that taking on the kinds of deep structural shifts needed to dismantle structural racism and design an equitable health system requires a different kind of leadership than what currently exists or is typically rewarded. While people came from different traditions and experiences in imagining what this kind of leadership might look like, there was general agreement that (1) we haven’t seen enough of it, (2) the people who do it are often under-resourced, and (3) conventional approaches to leadership fall short of what’s needed for structural change. 

Current strategies have made little progress in dismantling structural racism. Despite years of highlighting racial disparities in health outcomes and multiple studies and initiatives, disparities have worsened in many areas, from life expectancy to organ transplants to social drivers of health like income and household wealth. 

Study after study show that one of the biggest challenges in taking on structural racism is that our nation’s system of health is embedded in deeply held beliefs about the primacy of individualism, the unassailable power of capitalism, an assumption of scarcity and a zero-sum game, and, most deeply, a hierarchy of human value. It’s the last of these in particular that informs decisions about not only who receives treatments and who doesn’t, but whose voices are at the table, and listened to, when decisions affecting the health of communities are being made.

Dismantling structural racism requires an understanding of how these deeply held beliefs operate, as highlighted in these key insights from health leaders:

If leaders don’t believe that racism exists or matters, or if it threatens their own status, they will marginalize efforts to address it.

• Racism resists acknowledgement, which hinders truth, reconciliation, and healing. As one leader observed, “People will admit to murder before they’ll confess to being racist.” Truth-telling about the past harms done by the health system is key to gaining trust and legitimacy with people of color.
• Racism protects power and privilege, blocking efforts at change. The people whose voices most need to be heard often lack power and positional authority in a system. When people do come together to address racism, issues of privilege, sensitivity to criticism, different life experiences, and fundamentally different ways of approaching change make it hard to work together. Many leaders shared how their efforts to center anti-racism in their organizations or constituencies were marginalized and how critical it is to build partnerships around this work.
• Racism creates a lot of talk but little follow-through. Many people we spoke with shared deep frustration with the lack of real action on structural racism. As one leader reflected, “What’s not effective? Making a statement like ‘Racism is a public health crisis’ and then shutting up.”

Racism plays out at every level of the health system and every level of society, and any effort to dismantle it must be multi-dimensional.

• Pervasive racism requires pervasive strategies to dismantle it. People shared many stories and examples of how structural change had been undermined by the personal bias of a single leader or an organizational culture. Dismantling structural racism requires that we take on racism at all levels, from individual to interpersonal to institutional to the community, sector, and national levels. 
• Structural racism is complex and multi-faceted. There is no magic wand that will eliminate racial disparities in health outcomes. Even a specific challenge like closing the gaps in pulmonary and heart disease outcomes involves everything from addressing implicit bias among clinicians to race corrections in diagnostics to food access to wealth inequities.
• Racist structures work across institutional and sectoral boundaries. The structures that drive disparities in health outcomes aren’t limited to one institution or even a single sector. Inequities in housing, transportation, economic opportunity, and medical research require accountable leadership across multiple actors within healthcare alone. Even if the healthcare sector were to hold itself accountable for solving these issues, that would not be sufficient to lead the change that’s needed.

Racism blinds us to the opportunity to build a health system that is better for all.

• Racism pressures us to focus on repairing, not redesigning, the system. When we are faced with so much inequity being perpetuated by a system, we have to pay attention to minimizing harm from that system, but that often means that we don’t create the time and space to really imagine the system we want so we can build it.
• Racism prevents us from coming together and seeing our common cause. The pervasive idea that racism is about making things better for some people prevents us from acknowledging that the health system we have today doesn’t really work for most people and that designing a more equitable, human-centered system will benefit us all.

Section 04

What is the Leadership We Need?

“We need leadership that welcomes and values diversity in all forms so that people from both privileged and less resourced backgrounds can come together, realizing that we are actually all interconnected, and find a collective purpose that moves health leaders out of silos.”

– consultation session participant

Decolonizing “Leadership”

One of the challenges of advancing leadership to dismantle structural racism is that dominant cultural norms shape our views and beliefs in deep and persistent ways, including how we even think of leadership itself. For many, the only image of leadership is of people with positional power doing “leaderly” things, while others more or less follow them. Whether we believe great leaders are born, develop leaderly traits over time, adapt their leadership approach contingent on the situation, or just behave in leaderly ways, our dominant picture of leadership is still deeply individualistic.

That picture of individual, heroic leaders commanding and controlling others is so embedded in our culture, and in the healthcare sector in particular, that it keeps upending meaningful conversations about the kind of leadership we actually need. 

That’s a problem because structural change requires collective leadership—leadership that emerges among diverse people who commit to one another and to a common cause, where people not only work effectively across their differences, but leverage those differences as sources of innovation and resilience; where they develop a shared structural analysis and powerful shared strategies; and where they lead together with mutual accountability across and between organizational, sectoral, and even political boundaries to change the deep structures around them. 

To ensure that we’re working from the same understanding of “leadership ,” we first share this working definition that emerged from our Advisory Team and through our consultations:

Leadership is a collective, relational process
whereby individuals move themselves and others
through practices of discernment, growth, and change
to achieve health equity with and for those that our systems have pushed to the margins.

We should note that this picture of collective leadership doesn’t mean that we don’t need individual leadership. Collective change requires leaders who are willing and able to create and hold spaces where everyone involved can bring their diverse experiences, capacities, and approaches and work together toward a common vision.

Leveraging Our Collective Capacities

Taking on structural racism in our health system requires a diverse range of capacities that no single person or organization, no matter how large, can provide. One leader noted, “We need people who are contributing in diverse ways to address the issue: people focused on disrupting and deconstructing current systems, people who are envisioning the way new systems could operate, people who are identifying transitional strategies.” 

Based on the interviews we’ve conducted and the many accomplished leaders we spoke with, the research team believes that much of the necessary knowledge, skills, and abilities needed to dismantle structural racism already exists across our health system. That capacity is not being leveraged, however, in part because of  lack of resources for collective leadership approaches, in part because many people who hold these abilities are marginalized by the system, and in part because the spaces often don’t exist for that collective work to happen.

Given this, we collectively need to expand our focus from developing and supporting individual leaders to developing and supporting spaces in which diverse leaders can lead together—what we’ll call here Collective Leadership Spaces. These are spaces that are created when people who have a stake in changing a complex system, whether our national health system or a local community health system, organize to change that system.

Characteristics of Effective Collective Leadership Spaces

As researchers asked stakeholders across the health system about the leadership we need to dismantle structural racism, they described what a powerful collective leadership space looks like.

At their core, collective leadership spaces are made up of people who are deeply committed to structural change, regardless of their positional power or formal authority. Too often, leaders with positional power in the health system are convened to determine the vision, analyze the system, and determine priorities, when these leaders are invested in how the system is now. We instead need diverse leaders who are committed to deep systemic change and will build the power they need, engaging positional leaders over time in an ambitious agenda for change.

They comprise whoever is needed to do the work across organizational, sectoral, political, and cultural boundaries. While many people we spoke with focused on dismantling racism inside our individual institutions, others noted that won’t be enough to address the kind of structural shifts that are needed. As one leader put it, “A multi-stakeholder, multi-sector conversation and process is needed for systemic transformation. It should include all sectors, not only healthcare, but groups in transportation, human services, the private sector, philanthropy, the public sector. Then we can have a conversation about how we are going to structurally improve health outcomes.”

Within effective collective leadership spaces, these attributes and behaviors are essential:

• Honoring and building power at the margins. People we spoke with shared a strong belief that people from the most impacted communities bring the knowledge, commitment, and perseverance that’s really needed to take on a challenge like structural racism . “The locus of control and power center needs to shift, particularly when it comes to issues around governance and decision-making within our institutions,” one leader noted. “We need to quickly change those levers and incentivize power-sharing with the communities that have been harmed.”
• Developing and committing to a powerful vision and goals that reflect the group’s deepest values and highest aspirations. As one of our advisors, Tema Okun, noted, “People using their agency to create the kind of system they want may be the most radical collective action of all.”
• Fostering learning through action and deep reflection about how they are contributing to racial inequity, how the system they seek to change operates, and where the leverage points for change are.
• Intervening at all levels of the system, supporting people to interrogate their own identities, conditioning, legacies and biases; deepening awareness and change in their own organizations; and developing and advancing strategies for change at the largest levels.
• Advancing diverse, multifaceted strategies to address different parts of the challenge, rejecting easy answers and transactional solutions and committing to systemic action. While leaders we spoke with talked about common interventions like training programs and policy change, they also named market-based change strategies, “shifting the context” strategies, narrative change, and deep mindfulness and presencing work as possible interventions.
• Expanding accountability and building partnership. As one leader put it, “The burden of the work to fix racist systems is all on BIPOC leaders. This has to shift to include everyone, not just BIPOC. We all have a responsibility to act and change.”
• Working directly on mindset and narrative change, confronting dominant beliefs and stories with courage and crafting compelling new stories that express the best of who we are and who we can be. “There’s a narrative that health is something you create as an individual. The data doesn’t support that. We need to transform the mindsets of people who hold significant decision-making power,” a leader said.
• Persisting in the work over time. Anyone working on structural racism knows that this is intergenerational work, so collective leadership spaces need to be built to last for as long as their work is needed. As one leader noted, “Racism wasn’t built overnight. So it’s not going to be dismantled overnight. While each of us has a responsibility to continue to work towards progress, that progress will be gradual…Are we willing to really focus on the things that we might not see evidence of progress on during our careers or lifetime?”

Capacities for Convening and Supporting Collective Leadership Spaces

One of the common refrains from leaders is that the work of organizing and convening these spaces is important but undervalued and under-resourced. While some funders have increased support for collective leadership spaces, more is needed. “It’s really going to take collaborative partnerships that are given the resources and the authority to work together in a way that really addresses what we know are the real root causes,” one leader said.

Convening and supporting collective leadership spaces—what Beverly Wenger-Trayner and Étienne Wenger have termed “systems convening”¹—also requires specific capabilities. As one leader noted, “We can’t just throw people in a room and hope they figure it out. We need people with the ability to support these kinds of processes. Without those skills, these collective efforts can sometimes be a mess.” 

Some of the core “collective leadership convening” skills identified by leaders we spoke with are the ability to:

• Support people to excavate, acknowledge, and heal harm done to BIPOC by the health system and institutions within it, and establish and hold spaces where people can be courageous, accountable, and vulnerable in confronting this reality;
• Support stakeholders with diverse aspirations and disparate organizational priorities to align around a common vision, goals, and strategies, both to dismantle structural racism and to advance a better health system for all;
• Support the building of trusting relationships and deep allyship, which is critical for success. As one leader put it, “Many of our models for doing this work, and doing activism work in general, are very transactional. It’s often more about mobilization than it is about organizing for the kind of significant change that we need, which is really about relationships.”;

• Support groups to stick together through adversity and overcome efforts to derail and marginalize the work of dismantling structural racism and divide those doing the work;
• Support people to adopt a stance of continuous learning and experimentation, and to adapt analysis and strategies over time in response to new learning and shifting conditions.
• Name and challenge power dynamics and structures that impair us from adopting a transformational agenda for change and allocating resources to those leading the work on the ground;
• Center the work and decision-making authority in the diversity and wisdom of the group, resisting the tendency for “steering committees” or “executive teams” to assume power;
• Support groups to decolonize their ways of working by shifting from linear, top-down, either-or, conflict-avoidant approaches to change to approaches that are adaptive, iterative, deeply inclusive, and leverage conflict as a resource for innovation; 
• Host spaces in which people are welcomed to show up as their whole and authentic selves, bringing their heads, hearts, hands, and spirits to the work of whole system change.

Commitments for Collective Leadership on Structural Racism

Finally, leaders also shared specific commitments that they believe are important for anyone engaging in this work to take on, most notably:

1. “We must be able to lead with love and cultivate the self-awareness, vulnerability, and empathy that’s needed to do that.”
2. We must commit to risking ourselves and our social capital in this work; this is especially true for white partners. As one leader noted, “Equity requires bold leadership and white people who are willing to take the heat.”
3. We must commit to being changed—and changing ourselves—as part of this work. This means actively interrogating our own biases, beliefs, and assumptions and disrupting our own unhelpful mindsets and behaviors. “We need to turn the lens on ourselves, our own biases and prejudices,” one leader noted. “There is a need for greater self-reflection and self-honesty.”
4. We must commit to challenging our own cultural norms and preferred ways of knowing, being, and doing work. “The focus cannot simply be on supporting BIPOC people to assimilate into the given culture,” one leader noted. Leaders must understand and honor multiple ways of knowing and working. “We need to disrupt the legacy of white institutions to treat ‘equity’ as merely hiring more people of color who think, act, and do like them, but merely look differently than them.”
5. We must commit to centering the voice and experiences of people and communities most impacted in setting the vision and goals, analyzing what’s going on, and deciding on strategies. As one leader put it, this means “working in authentic partnership with communities, embodying the principles of ‘nothing for me without me.’”
6. We must be accountable to the work and to one another. One person noted that “being accountable means our ability to give an account of ourselves that we can be proud of. Accountability needs to be spelled out and needs to include people being served and equity principles.”
7. We must express our learning, awareness, and analysis in real action, moving far beyond works and commitments to the structural changes that are needed.

What’s happening now around leadership development?

An overview of the landscape of current programs supporting leadership development at the intersection of health and structural racism.

As CoCreative consulted many stakeholders across the health system about the leadership we need to dismantle structural racism in the U.S. health system, we also surveyed the landscape of programs focused on that challenge. We wanted to ensure that any new RWJF program developed based on our learnings should complement, not duplicate, existing offerings in the field and/or potentially build on programs that are already meeting the needs that leaders identified through this inquiry. 

We summarize our findings here and offer profiles of the top programs below for those who want to learn more.

First, many current programs are making strong contributions around aspects of collective leadership: advocacy, organizing, and civic engagement; narrative change; racism, oppression, and discrimination; and antiracist, equity-centered leadership. Some of the programs engaged participants in understanding the history of oppression and how BIPOC have been harmed by our health system and the institutions within it and in building the skills needed to support healing from that history, and many leaders we spoke with identified these both as important elements. 

However, many programs appear to underemphasize systems change capacities—seeing the whole system and the dynamics driving it, convening and supporting people to work across organizational and sectoral boundaries, working across all levels of the system, identifying high-leverage structural intervention points, and advancing multiple concurrent interventions to address different points. This implies that a program that supports these capacities might contribute something both new and needed in the field.

We also observed that the choice of delivery partner for leadership programs also influences the design and accessibility of the programs. For example, programs offered by universities were often limited to enrolled students and may also be influenced by the racism and power differentials in the university structure and culture. We were curious then about how programs could be funded, designed, and delivered by a diverse group of funders, curriculum creators, and facilitators with fewer institutional constraints.

We also examined whom the programs are designed for and found that most programs began the selection process with who would be a fit for the program’s leadership learning focus, rather than asking what areas of structural change needed work and then identifying who is ready and willing to advance change in those areas.

As we spoke with health system stakeholders about what a new kind of leadership program might look like, a number of program “design tensions” emerged. While these tensions could be perceived as either-or choices or possibly spectrums of choice, we believe that they are most powerfully conceived as tensions to leverage in advancing a more holistic approach to leadership. We looked at the existing landscape of programs through this “polarities” lens to see where the field might be out of balance in its approaches.

Programs Focused on Racism and Equity in the Health System

In 2021 and 2022 in particular, a number of new leadership programs have emerged that are aimed at addressing structural racism and health inequities in health and the healthcare systems. Several foundations, institutions, and networks have either redesigned existing programs or formed new programs to better meet the demands of this leadership challenge. Our researchers identified the following leadership programs that are centered on racial and gender equity in health or healthcare, and/or dismantling structural racism in health or healthcare.

RWJF Programs

RWJF also funds and/or sponsors a number of leadership development and related programs. Leadership for Better Health is the RWJF focus area that concentrates on leadership development programs that “supports and connects change leaders nationwide who are working to build a Culture of Health.” Examples include: 

Program	Target Population	Format
Culture of Health Leaders	Leaders from diverse groups who want to advance health and equity	Individuals
	Culture of Health Leaders (COHL) was a 3-year leadership development opportunity for people working in every field and profession who wanted to use their influence to advance health and equity. Through this program, leaders were prepared to collaborate and provide transformative leadership to address health equity in their communities. COHL is a RWJF collaboration with the National Collaboration for Health Equity, CommonHealth Action and The Center for Creative Leadership The Culture of Health Leaders represented a diverse group of lifelong learner and risk-takers from a wide range of fields (arts, architecture, business, community development and planning, education, faith/spiritual, health and healthcare, public health, technology, transportation, urban farming, and many others) who worked collaboratively across sectors, disciplines, and professions, and prioritized equity diversity and inclusion. Every year, the COHL program broadened the representation from fields and professions across the private, public, nonprofit and social sectors to build a truly diverse group of leaders. Through the COHL program, leaders across sectors, were given tools to:  Apply equitable leadership and collaborate across sectors, professions, and disciplines. Transform systems, policies, and institutions to be more equitable, diverse, and inclusive. Authentically engage community partners and members in building a Culture of Health. Frame issues and build public support to address them. Advocate for systemic and sustainable change. Learn More
Health Policy Research Scholars	Doctoral Students	Individuals
	Health Policy Research Scholars is a 2-year fellowship for full-time doctoral students who are entering their second year of study and are from populations underrepresented in specific doctoral disciplines and/or historically marginalized backgrounds. The HPRS is in partnership with the John Hopkins Bloomberg School of Public Health.  The HPRS started in 1992 and was designed for doctoral students with research-focused disciplines that can advance a Culture of Health. Past fellows were from economics, political science, psychology, architecture, transportation, sociology, social welfare, and environmental health. Each year the HPRS accepted 40 participants from a variety of academic institutions. Fellows participated in a variety of online activities during the academic year and in-person and/virtual events in the summer, fall and winter.  The HPRS was aligned with RWJF’s Culture of Health Action Framework. The program has been evaluated by the University of Michigan, Diversity, Research and Policy Program (DRPP). Evaluative information was not available at the time of this report.  Learn More
Interdisciplinary Research Leaders	Researchers and community partner	Teams
	Interdisciplinary Research Leaders is a 3-year team-based leadership program for researchers and community partners, including community organizers and advocates. Teams, which include two researchers and a community partner, use applied research to inform and support critical work in communities, to accelerate work and advance health and equity. IRL projects align with and support building a Culture of Health.  Over the course of the years the primary focus of the IRL applied research projects evolved to advance health equity and build a Culture of Health. The topics covered over the years included:  Cohort 1 (2016) Housing and Community Development or Early Childhood Cohort 2 (2017) Community and Individual Resilience or Youth Development and the Prevention of Violence  Cohort 3 (2018) Health Care Delivery in Rural America or Social Determinants of Health in Rural America Cohort 4 (2019) Community Development and Health or Clinical Practice, Social Services and Health Cohort 5 (2020) Community Environment and Health or Families and Child Health Cohort 6 (2021) Structural racism in healthcare or Structural racism and community health and well-being  Learn More

Other RWJF funded programs

In addition to programs offered through Leadership for Better Health, RWJF provides grant funding to support leadership development across its other three focus areas. These programs support students, community leaders, clinical leaders, and other champions for health equity, who are building a Culture of Health in a variety of settings. This section includes a brief review of current RWJF funded programs related to the intersection of health and/or healthcare, leadership development, and structural racism, though some programs may not heavily emphasize all three of these.

Section 05

Designing a Collective Leadership Program for Structural Change

How might we design leadership programs that support the collective leadership and collective leadership spaces we need to advance structural change?

While this research was focused on informing the next evolution of one of RWJF’s flagship leadership programs, we share here an overview of our recommendations as information for our allies in the larger field. 

It may be clear by now that the design of a leadership program that supports the kind of collective leadership we need is very different from what we’ve seen in the past. It must strategically convene whichever leaders are needed to address the deep structural challenges in the health system, resource those leaders to co-develop and advance strategic interventions, and ground leaders’ learning and development in real action. It must also evolve over time based on what’s most needed to support those doing the work.

3 Principles for Program Development

Based on equity organizing principles offered by Tatiana Fraser of The Systems Sanctuary, we offer here three principles that would apply to new program development. These principles are designed to avoid the downsides of centralized and ungrounded approaches to capacity building and ensure that any solutions are the best fit for the specific context.

1. Work from what is. Support collective leadership initiatives and leadership development resources that already exist to avoid duplication and waste of resources and talents.
2. Build from there. Build anything new lightly and iteratively, welcoming open feedback and critique, to ensure that it’s really adding value to the existing landscape of initiatives and programs.
3. Decentralize new solutions. Only build centralized leadership development programs when absolutely needed to minimize redundancies and ensure shared language and norms across participants in the program.

Proposed Program: Collective Leadership for Systemic Change

We considered several possible approaches for leadership programs that drive structural change; we recommend a program design that we’re calling “Collective Leadership for Systemic Change.” 

Here is a comparison of this type of program versus a more conventional leadership development program:

Program Scenario Assessment

In the table below, we assess each program scenario against the program design objectives:

When We Talked to Them

CoCreative began interviewing health stakeholders in late August 2021 and concluded the interviews in mid-December 2021.

The stakeholder consultation sessions were timed for key intervals in the research process when the insights and feedback from those meetings could most powerfully inform the emerging analysis of the U.S. health system, identify and prioritize structural intervention points, co-create a vision for the kind of leadership that is needed to achieve our goals, and shape the possible program pathways found in our final recommendations.

We offered a $75 honorarium to each interviewee as well as anyone who attended each stakeholder consultation session.

How We Engaged Stakeholders

To guide our inquiry about the challenge of structural racism in healthcare and effective practice in the healthcare and leadership development fields around structural racism , CoCreative developed and utilized  interview guides specific to stakeholder segments:

1. System Leaders who are leading organizations and/or structural change initiatives related to structural racism in the health system;
2. System Analysts who are observing and/or researching the challenge of structural racism in the health system ; 
3. Patient and Patient Advocates who have experienced and/or advocated to remedy structural racism in the health system.

This consultation process allowed us to develop a shared picture of the role structural racism has played and continues to play in the U.S. health system, collect insight on where the most powerful intervention points might be, and understand how health system leaders are experiencing the system around them. Our empathy interviews with patients and patient advocates grounded the analysis and program pathway design in real human experiences and complemented our systems perspective. We shared, socialized, tested and shaped our project goal, definitions, analysis and recommendations with others, expanding our circle of connections over time to build growing alignment about the why, who, what and how of this project.

What made this process unique was its iterative design and ongoing consultative process that involved the CoCreative consulting team, RWJF, the project Advisory Team, and public stakeholder sessions. At every point we tested and refined the emerging thinking and analysis, incorporating the insights and feedback of everyone in every cycle.

Appreciations

We recognize that the work to understand and address systemic racism is ongoing and continually finds its source in the experiences, perspectives, and labor of Black, Indigenous, and people of color. Countless individuals and groups, over generations, have dedicated their lives to the pursuit of equity. We wish to honor the legacy of their work. 

We are grateful to the 61 people we interviewed who contributed their wisdom, shared their aspirations, and spoke their truths about how structural racism manifests itself within the health system and what it will take to dismantle it. 

We appreciate the work of the Advisory Team members—Theresa Trujillo, Dr. Somava Saha, Michellene Davis, Dr. Linda Burnes Bolton, Dr. David Ansell, and Dr. Aletha Maybank—for informing and refining the project intent, the definitions of key terms used throughout the project, the landscape analysis, the leadership program strategy and design, and for their own courageous leadership to bring forward a more equitable health system. 

We thank Dr. Miraj Desai for sharing his research, advice, and consultation on the emerging insights from the field. 

We are grateful for the collaboration of David Peter Stroh in developing the system maps to analyze systemic racism within the health system. 

Finally, we thank the 150 people who attended stakeholder consultations sessions to co-design the collective leadership program.