This letter appears in HealthBegins’ April 2026 newsletter.

Dear friends,

As health equity champions, we have all seen programs struggle through a familiar life cycle: start with high hopes and great intentions, scrape for funds and patient recruits, strive to demonstrate impact. This struggle becomes more obvious as the variety of our programs increases — from treatment to prevention, short to long term, and direct care to structural reform. Some programs thrive, some wither. Some survive, some die. All have greater potential than they get a chance to realize. And that’s because they each live alone, separated from other efforts by siloed funding and reporting requirements.  

These days, when I see that untapped potential, I think of a garden — specifically, a simple but powerful approach called square-foot gardening.

Inexperienced gardeners’ first instinct is often to sow plants in rows, isolated and dependent on separate sources of nutrients and water. This approach might seem to work at first, but as soon as resources are limited, yield suffers and the gardener is forced to choose which plants to protect.

We often do the same thing when we manage a patchwork of programs to improve health equity and unmet social needs. In square-foot gardening, however, gardeners optimize their resources by drastically reducing the necessary space, water, and resources per program, compared to traditional row gardening. They plant an array of crops in a shared box, each in its own square foot. Different plants grow on different timelines and produce different crops. Yet the same soil, sun, and water support them all, and their coordinated planting and care maximizes their yield in a small space, nourishing up to seven times more produce from the same area compared to row planting.

Stories and metaphors are powerful tools to unlock thinking about what’s possible and what’s necessary. And based on the response we’ve received, I’m convinced that the square-foot gardening metaphor frames an essential shift in storytelling and strategy for this moment in population health and social needs programs and investments—a shift toward portfolio management. With this fresh mindset, we move from tending a lower-yield patchwork of programs to cultivating an intentional, interconnected, and higher impact portfolio.

Take the example of diabetes care and prevention. I recently spoke with grantee organizations that participate in a large, federally funded initiative to improve access to diabetes prevention, care, and education programs for underserved populations. In light of recent regulatory changes, grantees needed to understand how best to manage the wide range of programs they run across the country—from diabetes self-management training (DSMT) and the Medicare Diabetes Prevention Program (MDPP), to medical nutrition therapy (MNT) and remote patient monitoring. After reviewing the benefits of thinking like square-foot gardeners, the grantees’ network designed a course based on this approach to better organize their diabetes programs.

This illustrates how stories, metaphors, and tools can unlock action — in this case, moving from a patchwork to a strategic portfolio of interventions that span across prevention levels, time horizons, and needs. This way, we address multiple dimensions of health and equity at once. Each intervention complements others. And we don’t just solve individual problems; we build a cohesive strategy to yield long-term benefits for our patients, communities, and organizations.

In HealthBegins’ work, we help client partners reorganize their health equity investments beyond a focus on individual “plants” or programs and invest in a “square-foot gardening grid” that connects and supports them all. This is what the next level of health-equity impact requires. 

As resources for health are cut and restricted, we need an interconnected grid that enables our programs to share infrastructure. Braided funding and complementary reimbursement streams can serve as irrigation, supporting the whole grid rather than a single program. Shared staffing and resourcing models can reduce administrative costs. Integrated data and referral pathways act as pollinators, attuned to help move patients automatically from “square to square” as their needs evolve. In the case of diabetes programs, for example, when an A1c lab result comes back at 6.0%, the system should automatically “buzz” the MDPP coordinator. When it’s 8.5%, it triggers a DSMT/MNT referral.

This interconnected grid moves us away from hope-based referrals to data-driven automation. In a grid, we can also “companion plant” complementary services, like diabetes self-management training and medical nutrition therapy. And like diverse plantings in a garden, even if one “crop” or “square” loses funding, the grid remains.

A collection of programs is fragile; a diverse portfolio is resilient. Let’s grow our portfolios and the systems that support them to be stronger than the nearest crisis or the next grant cycle. If we want our interventions and investments to yield the results we seek — healthy patients, sustainable institutions, and more just communities — the goal isn’t just to manage programs in the same old way. It’s to think like a gardener.

Best, 

Rishi