Advancing Health Equity: Four Pillars of An Effective Leadership Approach

1. Ensure health equity is an organizational priority with C-suite visibility and commitment

Time and again we see well-intentioned efforts to create new functions — such as DE&I, sustainability or digital — fall short due to a lack of a cross-organizational mandate for change. Likewise, addressing health equity cannot be a siloed effort, but rather one that is incorporated into all elements of the business strategy, operations and culture, from the C-suite to the frontlines.

“The ideas and the opportunity of health equity need to be ingrained as part of the true culture of an organization,” said Dr. Keith Churchwell, volunteer president-elect of the American Heart Association. “It’s about how we ensure that care is being delivered equitably across all the populations we serve. It can’t be a bolt-on, an afterthought, or else it gets short shrift, and it becomes a burden on the organization. It needs to be integrated at the beginning to understand how to make the overall goal and objective successful.”

Health equity also needs to be central to the business strategy. The conventional wisdom has been that serving underserved communities is a money-losing proposition, something healthcare organizations do to fulfill their missions, and rarely if ever as part of their business strategy. But, in an increasingly value-based care environment where reimbursements are tied to outcomes, addressing health inequities has become a business imperative.

Embedding health equity throughout an organization must start at the leadership level. And for many organizations, that means designating a health equity leader. The exact title and organizational structure may vary depending on the organization’s needs — perhaps an existing leader could be responsible for the work, or instead an entirely new position or function created. Whatever the case, the health equity leader must be a change manager with a direct line of influence to the CEO and board and a voice in the C-suite.

“C-suite exposure is critical,” said Audrea Caesar, PhD, the chief diversity, equity and inclusion officer at UNC Health, where she also oversees the system’s health equity efforts. “There is no place else this role can sit to be effective. But it is not just reporting to the CEO. It is having the other C-suite members to work and partner with.”

Perhaps most importantly, the top-to-bottom commitment to health equity needs time to bear fruit. Solutions and success should be measured in years, rather than months. A common issue for some of these efforts, Dr. Churchwell said, is an expectation that the problem can be solved quickly.

“What’s needed are patience and true investment, and then getting the group together and thinking through what the real mileposts are,” Dr. Churchwell said. “What will success really look like?”

2. Set clear, specific, achievable goals with measurable outcomes and the resources to support them

Clearly defined goals for the leader and the function are critical. This includes looking at which inequities to address (e.g., gaps in care, outcomes or communities), what success looks like and how it’s measured.

The right path forward will vary by organization, based on their unique situation, their role in their communities, and where they stand currently on health equity. Organizations in nascent stages may need to start with internal education — defining health equity and why it’s important, and communicating this consistently and frequently. Mature organizations may focus more on finding the types of leaders who can build out processes, tools and infrastructure to start implementing solutions across specific populations. Whatever the case, you need the space and flexibility to adjust goals as needs evolve, as the leader’s capabilities and responsibilities grow, and as milestones are met.

Dr. Christina Harris, who became chief health equity officer at Cedars Sinai in 2022, dove into her job by focusing on the processes and tools needed to better collect, analyze and ultimately use data to understand disparities in patient outcomes. What data is available? How can we look at that data in different ways to understand variances in patient outcomes? “If you don’t stratify the data,” Dr. Harris said, “then you don’t know that some people are fine, and others are on fire.”

The next step is ensuring the right team is in place to meet those goals, including full-time employees who report to the health equity leader and individuals from other functions with a dotted line to health equity.

“You can’t just name someone to the role of chief health equity officer and expect them to fix it,” Dr. Churchwell said. “There must be a real investment in terms of people, money and structure. You’d never build a new campus, put one person in charge and assume it gets done. You’d have a whole team of architects, structural engineers and operations folks, among many others. It’s the same way with health equity. There must be infrastructure in place.”

Ultimately, health equity goals must align to enterprise goals. “If people cannot see how the goals align to the enterprise strategy, you will have a limited ability to influence in the organization,” said Dr. Neema Stephens, national medical director for health equity at Cigna Healthcare. “At the end of the day we must be intentional about outlining to our workforce how this work supports our enterprise goals — how it enhances patient safety and makes populations healthier. These outcomes can translate to business growth and medical cost savings.”

3. Recognize there is no one-size-fits-all candidate for a health equity leader

Executive performance depends on how well an individual’s capabilities, leadership style and expertise align with the specific context of the role and situation. This is certainly true for health equity leaders. Depending on the organization, the right person for a health equity job may be a clinician, a public health expert, a public sector leader, a DE&I specialist or even an operations lead.

Whatever the background, a health equity leader needs to blend knowledge of the clinical, social and environmental drivers of health inequities along with business acumen, change management skills and an ability to communicate complex and sometimes controversial issues with a variety of stakeholders. The person must be able to listen, influence and collaborate — inspiring change among stakeholders.

Is clinical experience necessary? Most of the health equity leaders we interviewed are medical doctors, and some organizations believe that having a physician in the role can increase the function’s credibility. “There can be a benefit to having a trained clinician in the role who has had experience directly within health systems — healthcare or public health,” said Dr. Aletha Maybank, chief health equity officer at the American Medical Association. Yet Dr. Maybank and everyone we spoke with agreed that a degree in medicine is not a requirement for the job. Depending on the needs and current leadership team composition, a non-clinician could make sense.

“I think it is neither necessary nor sufficient to be a clinician,” said Dr. Alice Chen, chief health officer at Centene. “But when you find a clinician who understands health equity, the drivers of health, inclusion and belonging, and also understands operations, the financial side of the business and the organizational dynamics — that is gold.”

UNC Health’s Caesar, for example, does not have a clinical background; hers is in public health. She has also worked within housing, economic development and education — all social determinants that affect health and are often drivers of health inequities. Prior to joining UNC Health, she worked for the city of Raleigh, N.C., creating and leading its new Office of Diversity, Equity and Inclusion. She cites her experience outside of healthcare as giving her a unique perspective. “We are an academic medical center, but we are also attached to the state, which adds complexity,” Caesar said. “Coming from government, I know how to navigate that complexity.”

Some organizations may pair a clinician with a business leader for shared responsibility for health equity. At Cigna, Dr. Stephens works collaboratively with Brooke Tomblin, the senior director of health equity, who has extensive experience in public health, population health management and healthcare operations.

4. Engage, influence and inspire a broad array of stakeholders

The ability to collaborate with and influence stakeholders through skilled communication is a critical emerging attribute for all leaders according to Spencer Stuart research, and was a common theme throughout our conversations with health equity leaders. As they establish the role and function, identify goals and processes, and seek to demonstrate impact, health equity leaders must listen to multiple constituencies, understand what is important to them and use that understanding to effectively gain buy-in and partnership.

Language and terminology matter here. Some groups may not view their work through a health equity lens, even if it’s highly relevant, and will need different terms to come to mutual understanding. Cigna’s Brooke Tomblin highlighted recent collaborative endeavors with various business partners to identify projects encompassing a health equity dimension. “Initially, when engaging with leaders, the response was that they were not actively involved in initiatives promoting health equity. However, upon rephrasing the question to inquire about any ongoing endeavors related to customer personalization, the response was almost always ‘Yes!’”

Specificity is also important. If all you have are broad platitudes — “to advance health equity” — then your efforts will run out of steam if not backed up by demonstrable and clearly communicated goals. Even the term “health equity” can have very different connotations.

“Focus on what you are there to do,” Dr. Chen said. “Explain, ‘We’re here to improve diabetes outcomes, and we need to collect and examine data by race to better focus our efforts on improving those outcomes.’”

Caesar points to UNC Health’s mission to improve the health and well-being of North Carolinians and others they serve. “It is not enough to talk about health inequities and disparities,” Caesar said. “We have to be very specific about the health inequities in our state and even drill down to the community level, understanding inequities that are unique to rural or urban communities, for example, and tailoring our strategies for each. When we get specific and talk about the challenges faced by a particular community, people perk up and they really listen.”

Health equity leaders should plan to collaborate closely with the communications and marketing functions — and vice versa — to ensure information and aligned messaging about health equity initiatives flow across all constituencies. More broadly, this partnership will be critical to any health equity leader’s ability to facilitate dialogue and forge consensus internally and externally.

Conclusion

As long as there are disparities in health outcomes along racial, ethnic, gender or socioeconomic lines, there will be a focus within the healthcare industry on understanding and reducing them. And as more organizations within the industry seek to address health equity, it’s possible to imagine a future where a health equity mindset permeates everything a healthcare organization does, and a health equity leader and function is no longer necessary.

However, for now many organizations are taking the path of designating a leader — be it creating a new dedicated position or augmenting an existing role — to drive health equity efforts, embed a health equity mindset throughout the organization and guide it through concrete steps to address outcome gaps in their patient population.

For those that haven’t begun the health equity journey, the time is now to get started. For those that have begun, keep moving forward and look for ways to serve as a role model for organizations earlier in the journey.