A Black doctor and imaging technician looking at a computer screen with an x-ray of a human torso
Image Credit: Accuray on unsplash.com

Few would deny that healthcare in the United States needs transformation. Our country’s cost of healthcare is enormous compared to other high-income nations. Despite this, according to Dr. Robert Shmerling at Harvard Health, the United States “scores poorly on many key health measures, including life expectancy, preventable hospital admissions, suicide, and maternal mortality.”

These poor outcomes especially impact people of color. Yet even analysis by race and income fails to get at the underlying cause of disparities in our health system. The very design of that system, where access and care are determined by one’s ability to pay, favors those with economic advantage and marginalizes those with less.

Few would deny that healthcare in the United States needs transformation.

Changing that design is crucial. Our challenge in achieving health equity, as in other challenges we face today, is not just about shifting behavior. It also requires a shift in what we think is possible for the individuals, communities, and institutions that constitute the healthcare systems and how these entities engage. And it is leadership that triggers this essential evolution.

The Need for Different Leadership

In 2021, when the Kaiser Family Foundation looked at how people fare across 27 key health measures, they found that Black, Hispanic, and Native Americans fared worse than their White counterparts in most areas due to chronic underfunding.

There needs to be more dialogue about what type of leadership is necessary to address these systemic failures. The Robert Wood Johnson Foundation (RWJF), a national health funder in the United States, has funded healthcare leadership programs as part of its strategy for nearly 50 years. The RWJF recognized that traditional leadership development was fruitful at the individual level but not for enabling systems change. As RWJF sharpened its focus on racial disparities in health outcomes, it recognized the importance of creating leadership programs that support diverse groups to lead across organizational and sectoral boundaries.

Our challenge in achieving health equity, as in other challenges we face today, is not just about shifting behavior. It also requires an evolution in how we think about leadership and change.

Over the past year, CoCreative, a consultancy that supports systems change collaborations, codesigned a new leadership program with RWJF that asked: What kind of leadership do we need to dismantle structural racism in the US health system?

As members of both the CoCreative and RWJF teams, we consulted with over 230 health system professionals, patient advocates, and patients through one-on-one interviews and open consultation sessions. Early in those dialogues, we asked people to share their vision of a health system that would work better. A compelling picture emerged:

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 wellbeing and quality of life for all people.

We asked what it would take to achieve that vision, given the history and current reality of racism in the health system. The result was 14 “structural shifts,” recommendations like putting systems in place to measure the impact of racism on health outcomes and eliminating racial bias in medical research and diagnostics. Many people emphasized the need to decouple the healthcare system from capitalist economic drivers.

Shifts like these require different leadership than we see practiced today. The vision interviewees pointed to is far more expansive and powerful than the traditional focus on individual leadership. It requires collective leadership and approaches that fundamentally challenge the notion of traditional “leadership development” programs.

Seven Evolutions of Leadership

Seven key themes emerged as we explored with healthcare stakeholders what is needed for a new model of leadership.

1. Collectively envisioning the future we want

People need time and space to envision a better system while simultaneously working to dismantle racism in the current one. As one person said, “Implementation without vision is just being busy, a lot of work that doesn’t necessarily get you to a meaningful outcome.” Cultivating a powerful shared vision and greater purpose for our work, especially amid urgency and emergency felt by so many across the health system, provides critical fuel for the transformational leadership we need. The power of vision works on both individual and institutional levels.

Based on a shared vision across the sector, the Healthcare Anchor Network, a group of 75 health systems committed to tackling structural determinants of health, pledged billions to new investments, inclusive hiring commitments, and local purchasing to revitalize economically marginalized communities.

Dr. Kimberlydawn Wisdom, the chief wellness and diversity officer at Henry Ford Health, has led major gains toward health equity for over 30 years, driven by a single personal vision: “At the 90- or 100-year mark, I want to be able to say, God willing, we’ve got an equitable society, and we’re moving toward a just society. I know my babies are going to get a fair shake.”

“Implementation without vision is just being busy, a lot of work that doesn’t necessarily get you to a meaningful outcome.”

2. Building collective leadership spaces

“We cannot advance equity in silos,” one interviewee noted. Yet we continue to rely heavily on individual leaders and organizations advancing isolated strategies, hoping these efforts will add to systemic change.

Participants in our interviews provided examples of diverse leaders coming together to conduct collective sensemaking and root-cause mapping. One case was a collaborative effort between students and faculty at the University of Washington to eliminate racially biased diagnostic factors for liver function. At health systems like Kaiser Permanente and Rush University Medical Center, healthcare executives collaborate with community stakeholders to develop comprehensive health equity programs.

Taking on complex challenges like dismantling structural racism requires shared space for joint planning and analysis and shared action across organizational, sectoral, political, and cultural boundaries. One respondent we interviewed stated, “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 leaders out of silos.”

3. Supporting those who are ready to act

A traditional view of leadership is that “leaders” have positional authority or formal power within an institution. As a result, leadership development programs have historically supported those leaders rather than those who play other roles across the system. This viewpoint reinforces hierarchy and considers a select few capable of creating change. In addition to undermining shared power, this helps to keep existing systems in place because those in positions of authority often do not want to risk their standing by disrupting those systems.

Often, leaders with little or no experience of inequities are called upon to lead health equity initiatives. The results are shallow analyses, weak agendas, low energy for change, and spotty implementation.

On the other hand, people from communities experiencing inequities bring the knowledge and commitment needed to take on 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 person noted. “We need to incentivize power-sharing with the communities that have been harmed.”

The Healthcare Anchor Network seeks to address this gap by providing training to middle managers in health systems on “leading from the middle.” Participants are supported in building cross-functional teams to advance health equity initiatives within their institutions. Of course, those with positional power must also take responsibility for leading on equity. They can start by leading with humility, sharing power with communities, and empowering those within their institutions.

4. Moving beyond the technical to trust

“Equity is relational, not technical,” one project advisor noted. While we need solid technical analysis and good data when taking on complex challenges like racial health disparities, these are not enough to support effective collective action.

Systemic change requires trusting relationships that enable risk-taking. We heard diverse examples of how talking about facts and statistics helped increase awareness but rarely led to action. However, when people in power were in direct relationships with those with lived experience, hearing the lived realities of racism and the human stories behind those statistics increased a sense of accountability in addressing them.

Building trust requires institutional leaders to make uncomfortable internal shifts. They must address their own assumptions and biases, and leadership programs should provide space and support for diverse groups to stay in relationships through adversity.

5. Deepening personal awareness and growth

Many stakeholders noted that taking on challenges like structural racism requires that leaders acknowledge their internalized ideas of cultural or personal worth, such as the implicit belief by some providers that White patients tend to make better health choices and are, therefore, more deserving of care. It also requires them to challenge their assumptions regarding how many choices they have in fighting structural inequity.

Unfortunately, our mental models of leadership often define success as power over—power over decisions, resources, hiring, and budget—rather than power with others. Evolving leadership means supporting ways of feeling, thinking, being, and doing that move away from these traditional models. Skills such as emotional and cultural awareness, as much as intellectual capacity, should be prioritized. So, too, should the development of a leader’s ability to deal with fear, uncertainty, and loss of control.

6. Advancing emergent and adaptive strategy

Leaders have too often attempted to address racial health disparities through individual programs rather than an iterative learning process of testing what works, adapting approaches based on what’s working, and continuously improving interventions over time. While strong execution of programmatic initiatives is essential, attachment to a specific program comes at the cost of adaptive learning and strategy. As one respondent noted, “There are a lot of things that we’re going to try that are going to fall flat. There are things that we’re going to try, and people might get upset. Leaders just need to say, ‘You know we tried this, we thought we were doing the right thing, we’re listening, we’re going to change up.’ Then, asking the people who are most affected, ‘What do you think could have made this better?’”

Leadership for systemic change requires comfort with experimentation. It also requires closing the gap between those doing the analysis—for example, frontline workers executing a program on the ground—and positional leaders in charge of strategy.

7. Centering truth and healing

One key aspect of collective leadership is foregrounding the harm done to those marginalized or impacted by existing policies, practices, and structures. This means organizations and even entire professions accounting for past damages done to BIPOC communities, as we’ve seen both the American Medical Association and the American Psychological Association do in recent years.

People across the health system also noted that truth and healing require “flipping the tables.” Rather than positional leaders controlling conversations on their turf, they should join dialogues already occurring in communities. This approach not only deepens learning and awareness but also fosters a deeper sense of collective responsibility. As Theresa Trujillo, an advisory team member on this project and co-executive director of the Center for Health Progress, put it, “We all are actors in this process, and carry water for these systems that harm us and exclude us.”

At the same time, several people warned against the “double tax” often placed on people of color in racial equity work. BIPOC professionals are not only expected to deal with the effects of racism in their own lives and work but also to lead antiracism or diversity, equity, and inclusion work in their organizations. They often become targets for resistant forces inside their organizations. This harm is compounded when White leaders at those institutions are celebrated as progressive, despite assuming far less risk personally and professionally.

Leadership Case: The AMA’s Equity Strategy

 The American Medical Association is a nonprofit organization embracing many of the evolutions of leadership described here. Beginning in 2019, the AMA House of Delegates launched its Center for Health Equity and hired its first chief health equity officer, Dr. Aletha Maybank. The Center, as stated in its strategic plan, “is charged with identifying ways to ways to dismantle racism in our health system as well as facilitating, strengthening and amplifying the AMA’s work to eliminate health inequities rooted in historical and contemporary injustices and discrimination.”

By resourcing a team explicitly focused on health equity, the AMA was able to draw on the power of diverse capacities while centering leaders like Dr. Maybank, who was ready to lead the work of deep equity across the AMA system.

From the start, Dr. Maybank and her team worked across the organization to build capacities and sustainable infrastructure for equity. This included developing the organization’s overall literacy and awareness about racial inequity in health and healthcare, especially with the AMA staff and board. Knowledge-building activities were curated around racial equity, the evolution of race, and how racism shows up, especially in health. According to Maybank, this work was foundational: “If the board hadn’t taken the Racial Equity Institute’s Groundwater approach training earlier [in 2020], the AMA would not be at this point with a strategic plan.”

Senior leadership explicitly named equity as a priority and defined it as an AMA-wide “accelerator” (along with advocacy and innovation) to support the AMA’s efforts to remove obstacles to patient care and prevent chronic disease. In addition, the relationship between Dr. Maybank and Dr. James Madara, the executive vice president and CEO of the AMA, became vital to advancing the work, especially given the impact of embedding equity at an organization like the AMA. Progress was supported by Dr. Madara’s commitment to deepening his own knowledge and understanding of structural and racial inequities.

As the Center team and people across the AMA began to draft the AMA’s first health equity strategy, they were conscientious about looking both forward and backward. They balanced the sense of urgency with that of longer-term visioning and planning. Their collective process resulted in the first vision statement to guide the work:

We envision a nation in which all people live in thriving communities where resources work well; systems are equitable and create no harm nor exacerbate existing harms; where everyone has the power, conditions, resources, and opportunities to achieve optimal health; and all physicians are equipped with the consciousness, tools, and resources to confront inequities and dismantle white supremacy, racism, and other forms of exclusion and structured oppression, as well as embed racial justice and advance equity within and across all aspects of health systems.

More striking, perhaps, was the organization’s willingness to publish an account of the AMA’s history related to racial equity as part of the strategic plan, including policies and practices starting in 1849 that had, according to the plan, “caused long-standing harm to historically marginalized and minoritized communities.” This historical content centered the truth of AMA’s history and provided insight into the role of a legacy organization in creating and maintaining hierarchy and facilitating systemic racism.

The process of truth-telling and reconciliation of the past and the bold call for racial justice in healthcare generated strong resistance, including threats of death and violence to AMA leaders. Solidarity from partners and commitments across leadership and staff supported the team through the thick of it.

In recognition that health equity is not possible through the actions of one organization alone, the AMA is establishing collective leadership spaces to take on racial disparities in health outcomes. One such collaboration, Rise to Health: A National Coalition for Equity in Health Care, unites individuals and organizations in shared solutions for high-impact structural change. Along with core partners like the Institute for Healthcare Improvement, Race Forward, the Groundwater Institute, and the American Hospital Association, Rise to Health engages members of the healthcare ecosystem in collective learning and action for equity and justice.

The Next Evolution: From Leadership Development to Supporting Collective Leadership Spaces

The seven evolutions above point to a more expansive understanding of the leadership needed to advance health equity and dismantle structural racism. They also underscore the need to identify different types of leaders and invest in them. The old model of “filling up” leaders with knowledge and skills is less effective than supportive collective conditions for new leadership to thrive.

Leaders we interviewed shared that spaces to explore new forms of leadership are important but undervalued and underresourced. While some funders have increased support for collective leadership spaces, more is needed.

To be clear, this isn’t an investment required only of funders. Organizational leaders must also commit their team members’ time and attention to collective leadership spaces. By making this type of development part of their formal roles and supporting them through their own journeys of learning and growth, we can ensure this leadership evolution is institutionalized.

While we’ve focused on leadership for health equity, we believe that the insights generated through this process apply equally well to any form of structural inequity—and, potentially, any systemic challenge. These seven leadership evolutions within our organizations can yield significantly different visions, strategies, and execution. Rethinking how we “do” leadership is needed to support healthier leadership—and healthier communities.