March 2021: Holding Our Institutions Accountable for Health Equity

Dear friends,


The past year has seen a surge of commitments from health system leaders to advance health equity, address racism as a public health crisis, accelerate social care integration, and move upstream to help dismantle the social and structural drivers of health inequity. It is encouraging to see health systems take these necessary steps.


But is it enough?


Is it enough for our institutions to start to transform the social and structural drivers of health inequity — without mechanisms in place to hold them, and ourselves, accountable? Once you’ve asked the question, the answer is clear.


One way HealthBegins is working to help our partners — and propel all of us more effectively upstream — is to elevate our understanding of what drives accountability for health equity at the institutional level. Fortunately, we already know something about how to build this essential work into the Upstream Movement.


To develop these practices, my colleagues and I have drawn on lessons from our own work advancing health equity through social medicine, health and human rights, and health policy, combined with expert research and models of institutional accountability and participation in realms beyond health.


So, what components of accountability do we need to have in place to ensure that healthcare institutions go beyond words and truly advance health equity?


Research indicates that institutional accountability for health equity requires five key ingredients: 


1) Participatory governance. With equity as both the goal and the guiding principle, this means that individuals with lived experience belonging to historically marginalized communities are involved in the institutional decisions — and accountability processes — that shape their lives.

2) Transparency. This is the bedrock of institutional accountability: the healthcare system or health plan reveals its processes and subjects them to public scrutiny.

3) Justification. An institution publicly provides a rationale for actions or decisions, including decisions to not do something, so that stakeholders may question it.

4) Compliance. This is the nuts and bolts, the monitoring and evaluating of health equity processes and outcomes, and it must be concrete and precise.

5) Enforcement. What happens when our institutions fall short on any one of these elements: participation, transparency, justification, or compliance? As a society, we still lack a system of institutional accountability that spells out clear consequences and sanctions for healthcare institutions that fail to improve health equity.


As we work to advance health equity and racial justice, we still have a lot to learn in pursuit of institutional accountability and, by extension, impact. But these foundational practices are a sound beginning, allowing us to take the best principles of accountability and apply them to our journey upstream — not only to set our sights on a more equitable horizon, but to ensure we get there.


If you have questions about how to start or deepen this work in your own institution, please don’t hesitate to reach out.



Rishi Manchanda, MD, MPH

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