Transforming Systems for Well-Being and Equity
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“The things that most threaten community health and economic prosperity, such as addiction, loneliness, economic inequity, chronic illness, climate catastrophe, racism, violence, and authoritarianism, are too numerous and too intertwined to deal with them one at a time. Such challenges are not truly separate, but rather symptoms of a broader systemic crisis—one that demands an equally broad response from all of us as system stewards.” - Bobby Milstein, A Brief History of Stewarding Health, Wealth, and Well-Being
When we see communities as dynamic systems, we see how vital community conditions work together to produce health and well-being. Thinking in terms of systemic drivers illuminates the institutional structures and patterns in our social, political, economic system that manifest health and well-being disparities. Systems transformation offers a framework for system stewards to alter the underlying, systemic drivers of health and well-being inequities.
Systems transformation means changing or redesigning systems to shift the conditions that hold a problem in place. Shifting conditions for systems change requires stewards to think and act in new ways to create new legacies of dignity and inclusion.
Stewards are people and organizations who share responsibility for working together with others to transform the system we inhabit today, and expand opportunities for all people to thrive tomorrow. Inspiring examples of systems stewardship demonstrate our power and potential to design the next system for equitable well-being.
This guide names key community systems and priorities for transforming them (the “What”), identifies system actors (the “Who”), and shares ways system stewards are working to secure vital conditions for community health and well-being for all (the “How”). Resources included in this guide highlight stories of community transformation, and bright spots and tools to implement change-work.
What: Our healthcare system is characterized by fragmentation, high costs, and high demand for urgent services for acute care for illness and injury. The healthcare system in the U.S. has produced significant disparities in healthcare access and quality, and has prioritized treatment of disease over health promotion and disease prevention.
Who: Actors in the healthcare system include hospitals and health care institutions, provider networks, insurers, pharmacies, medical transport, nursing care facilities, rehabilitation facilities, telehealth services, home health care, and public health agencies.
How: Health system stewards are investing in the vital conditions for health and well-being by leveraging community benefit dollars and multi-sector partnerships. Through scaled approaches, like Medicaid expansion and community health workers, stewards are improving health outcomes through increased access to care. “No wrong door” policies and approaches that provide a continuum of services and supports are filling gaps in care caused by fragmentation. And innovative approaches to prescribe healthy food and physical activity are creating a culture of health.
Faith Community System
What: Faith community systems provide vital social infrastructure that strengthens well-being by building community and creating social support networks. In addition to social infrastructure, faith communities often have physical assets like fields, gyms, auditoriums, and libraries, all of which can be leveraged to support community health and well-being.
Who: Actors in the faith community system include faith-based groups, such as mosques, synagogues, temples, churches, and other communities of spirit, and their service arms.
How: Faith community system stewards are connecting and partnering to build community, support leadership development, and advance social justice causes and issues of health equity. Examples include efforts that advance food and housing security, chronic disease prevention and management, mental health promotion, violence prevention, and drug rehabilitation, among others.
What: Our justice system is characterized by institutional and systemic racism, of which police violence and mass incarceration are demonstrative. The system produces high levels of recidivism, disenfranchises felons from their civil rights, and has manufactured a school-to-prison pipeline.
Who: Actors in the justice system include police departments, the judicial system, the prison system, the juvenile justice system, and schools.
How: Justice system stewards are initiating community policing reforms, changing mandatory drug sentences, reversing drug convictions, reforming school discipline, divesting from private prisons, and expanding voting rights to inmates and felons on probation or parole.
What: Our food system produces high levels of food insecurity, creates barriers to healthy food access, and manufactures food deserts. The food system generates staggering amounts of food waste, and through intensive farming practices, degrades and depletes environmental resources.
Who: Actors in the food system include food growers and producers, distribution systems, food retailers, and institutional food buyers.
How: Food system stewards are leveraging institutional purchasing power to improve local food systems, advancing regenerative agricultural practices, expanding summer food and universal food programs in schools, among many other promising strategies.
What: Our financial system has produced severe economic inequality through racist and unjust processes that systematically disinvest in low income and communities of color, concentrate poverty, and deprive black and indigenous people and people of color wealth-building opportunities.
Who: Actors in the financial system include banks and financial institutions.
How: Financial system stewards have created entities such as community development financial institutions, community development corporations, and community land trusts which invest in communities and secure resources to improve vital conditions. Stewards are pursuing transformative initiatives to increase homeownership, seed entrepreneurship, and guarantee a basic income.
What: The housing system has produced many sprawling suburbs that have subdivided green fields, encroached on agricultural land, and created communities far from job centers that lack necessities for residents to live healthy, productive lives. In many major cities, the housing system has produced a crisis of affordability that displaces many lower income communities and communities of color. In other places, the housing system has produced neighborhoods with concentrated poverty, blight, vacant housing, and substandard housing conditions. The housing system fails many and has produced an unacceptable level of homelessness and housing insecurity.
Who: Actors in the housing system include housing developers, housing authorities, planning authorities, and banks and financial institutions.
How: Housing system stewards are adapting zoning codes to develop mixed-use neighborhoods, implementing inclusive zoning for affordable housing, developing permanently affordable housing, advancing initiatives to increase homeownership, and creating supportive housing and a continuum of housing for populations in need.
What: Our transportation system preferences automobiles to the extent that it has shaped communities through auto-centric development, led to disinvestment in public transportation, and created a system of roads and transportation infrastructure that is costly and difficult to maintain. The transportation system is a significant source of air pollution and greenhouse gas emissions, and produces an unacceptable number of transportation-related injuries and deaths.
Who: Actors in the transportation system include transportation and highway departments, transit agencies, and planning agencies.
How: Transportation system stewards are encouraging transit-oriented and mixed-use development, expanding active transportation infrastructure, reclaiming streets as public places, prioritizing safety through transportation infrastructure design, expanding bike and car share programs, and experimenting with innovative strategies, like congestion taxing.
What: Education is an engine of economic and social mobility, with implications for health and well-being that extend across the lifecourse; yet, our education system fails to deliver on its promise to provide a good education for all regardless of background and ability. Disparities in access to education, school funding, school discipline, quality of education, and educational achievement exist and are perpetuated across generations. These problems are held in place by persistent segregation and discrimination in education, challenging education funding paradigms, and rising costs of higher education, among other conditions.
Who: Actors in the education system include public and private pre-K, K-12 schools, school districts, and colleges and universities.
How: Systems stewards are shifting conditions to address disparities in educational outcomes, like reforming school discipline and improving access to early childhood education, mentorship, college readiness and access, degree completion, and STEM recruitment programs. Stewards leverage school settings to provide health care, dental care and counseling services, and expand food access.