5 Ways to Hold Institutions Accountable for Health Equity

This is part one of our series on the Five Mechanisms of External Accountability for Health Equity. Read parts two, threefour, and five.


Part 1: Community-driven Governance and Monitoring

As health care institutions push to address health equity, the underlying assumption is that all that is needed is more internal work; that institutions can simply hold themselves accountable. While this is a necessary component, it is insufficient. As evidenced by the persistence of health inequities, there also needs to be strong mechanisms by which others–including employees, patients, community residents, policymakers, and government–can hold healthcare institutions accountable. Adapted from robust ideas and research in other sectors for how institutions can build these systems of accountability, HealthBegins has outlined Five Mechanisms of External Accountability for Health Equity (see image below). 


HB 5 Mechanisms of Accountability

In this blog series, we’ll review each of these mechanisms. At the core of all of these mechanisms is the need for community-driven governance and monitoring, which is the focus of this first piece in the series. As organizational psychologist Judy Freiwirth writes, this approach is “based upon the philosophy that a constituent’s ‘lived experiences,’ knowledge, and right to self-determination are critical values for organizations to embrace.” Embracing community-driven governance and monitoring helps ensure the success of everything a healthcare institution does to advance health equity. It holds the other four external mechanisms of accountability together, and it is also a way to monitor how well healthcare leaders are implementing interventions and internal mechanisms of accountability–such as using dashboards and performance incentives–to advance health equity. 


Community-Driven Governance in Practice


With notable exceptions including federally-qualified health centers (FQHCs) and some publicly-governed hospitals, many health care institutions and health plans are governed by boards whose members don’t typically belong to economically or socially marginalized communities and who don’t have lived experience dealing with structural inequities, including structural racism. This lack of diversity reflects a philosophy of governance that has allowed structural harms and health inequities to persist. In contrast, community-driven governance is about shifting both how boards work and the work boards do. It means adapting new models of local collaborative governance that go beyond looking to patients and community members merely as advisors, and instead treats them as partners in governing.


Research on community engagement demonstrates that these models exist on a spectrum where institutional executives and boards either increasingly cede governance decision-making authority to people with lived experiences, or conversely, where constituents and communities increasingly claim their right to self-determination and make demands for power over institutions. Here are three models from the nonprofit sector of what this looks like in practice:


Community consultative boards


In general, community consultative boards refer to a shift in the priorities and approaches of institution’s leaders and boards. Instead of sitting in the boardroom or C-suite offices and engaging community members once every three years for a needs assessment or strategic planning process, leaders and board members focus time and resources on developing relationships with key community members and constituents. Boards forgo infrequent focus groups that center an institution or board’s questions and priorities to regularly participate in learning conversations with constituents to identify community needs and plan responses.


Governance partnerships with communities 


Governance partnerships with communities describe when decision-making power for an institution’s most important strategic decisions shifts from a small group of overseers (the board) to a larger forum of active constituents and/or members of the organization. This can be done through committees comprised of community members that share specific decision-making authority and responsibilities with institutional boards. Labor-management partnerships in healthcare are an example of governance partnerships, in which executives and boards share governance decisions with employees.


Constituent-led boards


These boards are a powerful form of community-driven governance, but are uncommon in health care. FQHCs, which have their roots in the civil rights movement, are an exception; fifty-one percent of their board members are required to be constituents.


Community-Driven Monitoring in Practice


Community-driven monitoring is where constituents and beneficiaries with lived experience–both those whom the institution serves and hires–are involved in monitoring how well the institution advances health equity and racial justice. This can take three forms:


Constituent / Citizen Monitoring and Local Collaborative Governance


Constituent or citizen monitoring is an approach where people from marginalized communities analyze policy issues, develop their own policy priorities and strategies, build alliances with others, and hold institutions accountable for meeting their needs and running effective programs. One example of this is the National Citizens’ Monitoring Project on Community Development Block Grants (CDBG). Launched shortly after CDBG legislation was passed in 1978, it researched, monitored, and evaluated CDBG’s impact on economically marginalized communities. At its peak, over 80 national, regional, and local organizations were involved in monitoring CDBG’s implementation in 43 cities. Community leaders used this research to influence national and local policy change, including a federal requirement that 75 percent of all CDBG funding benefit lower-income people. And in Philadelphia, work by the monitoring coalition led to a commitment that 60 percent of Philadelphia’s community development funding go to non-profit housing. To realize the potential of constituent monitoring, health systems can support and join local approaches to collaborative governance, in which public, private, and nonprofit organizations (including community-based organizations) and community members work together to review data, make decisions, and monitor progress towards health equity. 


Participatory Action Research and Popular Education


Participatory action research is an approach that seeks to situate power within the research process with those who are most affected by the issue or program being studied. Academic medical centers and researchers apply some of these methods using Community-Based Participatory Research (CBPR) to help increase community participation and oversight of healthcare research. Others, including Virginia’s state department of health, have used these methods to help share decision-making authority and monitoring responsibilities with community members. 


Community Organizing 


Community organizing builds a power base and negotiation position for members of marginalized communities to hold healthcare institutions and systems of power accountable and push them to do what’s right. To fight declines in real wages due to healthcare premiums, The Greater Boston Interfaith Organization used community organizing to help pass a healthcare cost containment bill and drove the Massachusetts Attorney General to regulate the Beth Israel Lahey health system merger. Organizers pushed for the health system to (1) abide by seven-year price caps; (2) treat more MassHealth (Medicaid and CHIP) patients; and (3) set aside $72 million to support low-income communities and communities of color.


Seven Questions You Can Ask to Assess and Strengthen Community-Driven Governance at Your Healthcare Institution


Strengthening community-driven governance and monitoring at your healthcare institution begins with an honest assessment of its current governing structure and involving community partners in those discussions. HealthBegins recommends finding opportunities to ask and discuss these seven questions to help hold your health system accountable for health equity:


  1. Is active engagement of communities, including residents with lived experience and who belong to historically marginalized communities, an explicit responsibility of your institution’s board?
  2. How would you describe your institution’s approach to community-centered governance? Do your boards and governing bodies have constituent representation? Do constituents make up half of these bodies? Do they make up the majority of members?
  3. What is the racial, ethnic and linguistic composition of the board and community-centered governance bodies?
  4. What governance decisions and responsibilities are shared with or assigned to your constituents?
  5. What mechanisms does your institution have in place to solicit and receive concerns about health inequities and racial injustice from community-driven organizing and monitoring efforts?
  6. In the last year, what health equity and/or racial justice-related concerns have community residents identified and shared with institutional leaders?
  7. What resources does your institution provide to BIPOC board members and/or collaborating community representatives / organizations so they can participate on a level playing field with others involved in governance?


These questions can be asked by formal leaders–including executives, boards, and managers during C-suite and board meetings–and by informal leaders–including patients and non-managerial employees during task force gatherings and as part of team meetings. These are also questions that community-based leaders including policymakers, social service providers, and advocacy groups can ask of healthcare institutions as well.


If you’re looking to strengthen community-driven governance and monitoring at your institution, consider identifying and reaching out to a local constituent-led or community-based organizing effort or power-building organization and ask how you can work together to strengthen this mechanism of accountability to improve health equity. 



By: Rishi Manchanda, Sadena Thevarajah, and Kate Marple


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