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Developing systems understanding to address health equity in the U.S.

Reos Partners
April, 2019


Learn how a multi-stakeholder team developed strategies to improve health outcomes and reduce inequities in the USA by improving systems understanding. 


The United States spends more on healthcare per-person than any other country, but when it comes to rankings of industrialized countries for health indicators like infant mortality and life expectancy, the country is at or near the bottom. The United States also shows significant disparities in morbidity and mortality, divided by race, income, and geography.

In order to catalyse open and reflective strategic thinking and conversation about the possible futures of health and health equity, the Robert Wood Johnson Foundation supported Reos Partners in convening a multi-stakeholder team of system leaders to examine the systems and relationships that produce individual and community health and illness.

This project aim is to develop a shared understanding of the systems that contribute to health inequities to inform strategy and decision making.


As one participant said, “In the United States we don’t have a health care system, we have a sick care system.” Further, entrenched inequity leads to great disparities in health outcomes across population groups. Depending on ethnic background,
socioeconomic status, gender, sexual orientation, legal status, or mental and
physical capabilities, one individual is more or less likely to die of certain
diseases, have a shorter life expectancy, and be vulnerable to serious physical
and emotional harm than another.


The resulting Health System Scenarios explored what could happen in the United States that would either support or undermine the development of systems that support better and more equitable health outcomes.

Through the scenario creation process, participants developed:

  • A shared framework and language about the future of health in the United States,
  • Better understanding of influences on health and health equity, and
  • An increased understanding of the actors and institutions that might influence the future of health in the United States.

Participants are applying their new understanding in many different ways. Some who work directly in healthcare are increasing their focus on prevention, while others working in social domains are moving beyond program approaches to more systemic ones.

At the end of the process, scenario participants reported new commitments to working systemically and collaboratively. One participant shared, “As a result of our time together, I see much more opportunity for cross-sector partnerships to advance health and equity. There is a lot of uncommon common ground here. It's not just individual communities and social groups that are worried about health and equity. There's a case to be made by the business sector that we need to invest in a different way to improve people's health and reduce the inequities that we see. We can bring the business sector, labor, public health, so many different sectors together to address health and equity in the United States.”

Reducing health inequities in the United States and improving health outcomes will not be easy or direct, and will require action in many areas. The scenarios are one
strategic tool that can help accelerate progress toward needed changes.  


100 percent of participants report that they believe their capacity to create change increased, and 86 percent report that they took action or changed their behaviour as a result of participating in the scenarios process.  

30 percent of participants report seeing changes as a result of the Scenarios Process. On average, they believe that the contribution of the Scenarios Process to the change was 60 percent.

Targeted action to address social factors that influence health

In one health system the scenarios process has contributed to health care leaders and hospitals adopting a more strategic focus on addressing social factors that influence health outcomes. This has included fostering a conversation about how to allocate health care assets in order to improve equity and opening up a new food bank inside a hospital.

One participant reported that, through the process, they realized the importance of health care providers engaging in prevention and education, in addition to treating diseases. As a result, they are now working with the Board of Directors of their health system and local business leaders to help combat opiate addiction and infant mortality in their city.

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