Applying a Systems Lens to Advance Health Equity

This is the ninth installment of a 12-part blog series discussing doing evaluation in service of racial equity as part of a collaboration with the Kellogg Foundation. The views expressed here are those of the authors and do not represent the views of any partner organizations, including the Kellogg Foundation.

Work that advances health equity comes in all manner of places and contexts. Because health equity work is highly intersectional, we have to simultaneously consider the roles that both power structures and social contexts play in shaping individual health outcomes. There are many researchers, health care providers, community partners, funders, and government entities actively working to address health disparities and advance health equity.

Addressing the Structures and Contexts Shaping Heath Disparities

While structural and social determinants of health are distinct concepts, they are intimately connected. Structural determinants (e.g., economic systems and institutional practices) create the context within which social determinants (e.g., socioeconomic status and employment) operate. For example, federal and state policies shaping healthcare delivery services and employment status can directly impact an individual's available health coverage options, which in turn influences their access to health-promoting resources and ultimately impacts individual health outcomes. In this example, multiple systems are implicated.

To achieve health equity, it is imperative to address both structural and social determinants of health. This involves advocating for policy changes, promoting economic empowerment, and strengthening social support networks. If we only focus on individual interventions and changes among the social determinants, the systems that produce inequities will remain in place. One strategy we can use is to look at preventive measures that aim to stop health disparities before they happen.  Moving “upstream” to prevent disparities before they occur necessitates that we look at both structural and social determinants.

Moving upstream involves applying a systems lens to our work. As we have discussed in this series, the Kellogg Foundation’s Practice Guides provide a solid foundation for learning how to think about systems in our evaluation work. In practice, applying a systems lens is about learning to see social phenomena from a holistic perspective to consider the entirety of a system, including its various elements, interactions, and interdependencies. We may start with understanding a particular program or intervention, but we don’t stop there.  Rather, we consider how the intervention fits within and contributes to the outcomes of the overall system. 

Using Equity-centered Evaluation to Help Align Systems of Care

Evaluators bring a wealth of experience to health equity efforts. In my evaluation practice, I have worked at and with organizations that focus exclusively on systems change strategies. In that evaluative work—whether that is assessments, exploratory work, or formal evaluation—we aim to better understand the parts of the system and capture both expected and unexpected ripple effects. For example, I supported an organization that explored how to integrate its services into a system being implemented by the Help Me Grow system model in Los Angeles County. The HMG system is an example of an upstream intervention that works to align systems of care for the benefit of youth. Practitioners implement HMG by combining the following elements:

• Centralized Access Point:
  • HMG serves as a centralized hub where parents, caregivers, and healthcare providers access information, resources, and referrals related to child development. This hub ensures that families have easy access to the support they need. Access to updated data to understand referrals, uptake in services, and screening rate is also a key feature of the system.
• Developmental Screening and Assessment:
  • HMG provides tools for developmental screening and assessment to identify potential concerns. These assessments are available to families in local health clinics, pediatrician offices, and at the local hospital among other settings.
• Connecting Families to Services:
  • If concerns are identified, the Help Me Grow system facilitates connections to appropriate services and resources. This often includes referrals to healthcare providers, early intervention services, educational programs, and food benefits. It strives to provide services that are culturally sensitive and linguistically appropriate, ensuring that families feel heard and understood.

An intervention like HMG is meant to advance health equity by intentionally identifying leverage points in the healthcare system where information and support can be provided to families that need it. Resources already available in the systems are made more accessible to families when all healthcare delivery organizations work together to better align their services. This type of alignment work is both difficult and extremely important.

Advancing Health Equity through Research and Evaluation

At RTI, the Transformative Research Unit for Equity (TRUE) team’s work on the structural determinants of health focuses on building the evidence base to help transform systems to achieve health equity.

In the pursuit of health equity, we cannot afford to overlook the structural determinants that shape health outcomes. Equitable evaluation methods are an important tool to help us see and know systems so that transformative work focuses on the root of the problem.