There are years that ask questions and years that answer.
—Zora Neal Hurston, Their Eyes Were Watching God1
We are at a watershed moment in health care and public health, when enduring questions about equity are front and center. Health inequities that became evident in the COVID-19 pandemic, the growing realization that structural racism is a foundational driver of health, and calls for police violence to be recognized as a public health issue have highlighted long-standing disparities in health by race and ethnicity in the United States. 2,3 As this country becomes increasingly racially and ethnically diverse, meeting today’s challenges in our public health and health care systems calls for leadership approaches that center equity to ensure each person has the opportunity to live a healthy life.
Current crises in this country are forcing health care and public health leaders and professionals to examine and reorient systems that have, for decades, produced the health inequities clearly exposed in 2020 4—and we are discovering that our leaders are inadequately prepared to respond. Positioning these fields to have explicit, intentional, and consistent plans to identify, address, and monitor health inequities is essential. However, there is a gap that lies between being able to recognize the problem and having the skills, mindset, and commitment to effectively implement a remedy. If we could bridge this gap, we could address the roots of health inequities rather than only pledging to do so.
Bridging this gap will require public health and health care leaders who have a deep understanding of the structures, policies, and practices that underlie inequitable outcomes, in combination with more traditional leadership skills. These leaders will need new knowledge; new skills; a greater consciousness; and the courage to challenge assumptions, realign values, and embrace the kind of change that fundamentally alters the way this country responds to disparities in health outcomes. Here, we offer an equity-centered competency framework for leadership development programs as a guide for developing leaders with the mindset and skill set needed to address equity-based challenges in the U.S. health care system.
A New Direction for Health Care Leadership Development Programs
The U.S. health care sector is a $3.6 trillion industry 5 (as of 2018) and an estimated $166 billion is spent annually on leadership development in the United States, 6 where many health care leadership development programs are sponsored by academic health centers. For decades, health care leadership development programs have been built on a masculine, Eurocentric framework with little evolution in leadership competencies. 7 Only recently have leadership development programs started to include frameworks that also embrace Black, Indigenous, and People of Color (BIPOC) perspectives. However, equity, diversity, and inclusion (EDI) topics (see Table 1 for definitions) are often presented in a single lecture/seminar or as a separate unit or module, if they are included at all. 8–10
In highlighting long-standing health inequities, the COVID-19 pandemic also demonstrated inadequacies of the frameworks underlying most current health care leadership development programs. This pandemic is a harbinger of many challenges to come—from the impact of climate change on human and economic health to the insecurities of deeper social unrest. Re-tooling leadership development programs to embrace a more inclusive model relevant to today’s challenges and contextual realities will help equip leaders in health care and public health to meet such slow-motion VUCA (volatile, uncertain, complex, and ambiguous) challenges. 7 We must maximize the return on leadership investment dollars by exploring paradigms that equip leaders with the skills, knowledge, humility, empathy, and attitudes needed for these times. 11 Leadership principles and EDI principles can no longer be seen as separate training topics. They must be equally weighted and fully integrated in terms of content and skill acquisition if we expect leaders in health care and public health to rise to the challenges in front of us. 12,13
A year like 2020 raises many questions. For leadership development programs, the important questions include: What does a program that integrates both traditional leadership and EDI competencies look like? What are the most important skills to cover? How do you incorporate impactful learning events for participants along the continuum of thought diversity and fully include topics like systemic racism? 14,15
An Equity-Centered Leadership Framework
In response to such questions, and based on our collective experience designing and leading leadership development programs and health equity efforts, we offer an equity-centered leadership framework of integrated competencies to support the development of leaders for tomorrow—visionary leaders who can break down silos, tackle the root causes of health inequities, and share power to effectively partner with communities and create sustainable change in a rapidly evolving landscape (see Figure 1). Developed to guide an equity-focused, interprofessional leadership development program, 16 this framework interweaves leadership and EDI conceptual knowledge and skills-based teaching for health care and public health professionals (see Appendix 1).
The equity-centered leadership framework’s competency set joins traditional leadership skills with contemporary EDI skills, grouped into 4 domains: personal, interpersonal, organizational, and community and systems (see Appendix 1). Competencies in the personal domain focus on cultivating a mindset of self-awareness of leadership style and strengths, as well as an appreciation of individual differences to support engagement with diversity. Competencies in the interpersonal domain focus on developing the skill sets of building and leading through relationships with diverse others. The organizational domain competencies focus on developing a systems orientation to leadership and assessing and understanding strategies to use evidence to shift organizational culture. Finally, the community and systems domain competencies focus on developing skills to engage and partner with communities and stakeholders to address current and future structural drivers of health equity.
As this framework demonstrates, EDI principles should not be treated as just one of a handful of competency focus areas, but rather as foundational; they must be equal to, addressed alongside, and woven together with traditional leadership competencies. For example, emphasis placed on EDI concepts, such as intercultural sensitivity and transforming systemic power structures, must be equal to that placed on traditional leadership concepts, such as self-awareness, creating a vision, and negotiation. 16 Self-reflection and self-awareness must go beyond a simple 360-feedback assessment to the examination of humility and one’s ability to listen deeply, create space for the voices of others, and genuinely share power. Leaders must build skills in both allyship and managing difficult conversations. And while discussions about successfully leading change are important, they must be braided with conversations about changing the policies and practices that have historically led to health inequities. An equity-centered leadership framework such as this will equip leaders with the mindset and skill set to thoughtfully challenge the paradigms that lead to inequity and health disparities, to approach their work in more equitable ways, and to capitalize on strategies that have long been embraced for their effectiveness in leadership. 10
The murders of George Floyd, Breonna Taylor, and many other BIPOC individuals at the hands of law enforcement have spurred the awakening of a new civil rights era in the United States, and we must not ignore this call to action. Police violence, the COVID 19 pandemic, intransigent inequities by race and ethnicity in the health of our communities, and structural drivers of health are signs of the complexities involved in providing equitable opportunities for all to live healthy lives in this country. Health care is only part of this complex picture and does not exist in isolation. Leadership programs across all sectors need to rise to this challenge.
However, leaders in health care and public health must begin to understand and address these signs as elements of a system of interlocking vulnerabilities and oppression, or we risk struggling through these current crises only to fall back to the status quo. We can and must do better for our communities and our neighbors.
Leaders must be equipped with the knowledge, skills, and attitudes that can prepare them to bring us through these challenging times and help us thrive in new and more inclusive environments and organizational cultures. The full integration of EDI principles with traditional leadership competencies has the potential to take leadership development programs to the next level. Together, these principles form the foundation of the leadership we need for the future. Leadership development programs that adopt this updated and expanded view of leadership will prepare leaders who have the potential to finally—and completely—address the root causes of health inequity, not just in the short term, but for generations to come.
The authors thank Carol E. Lorenz, PhD, for her editing support and Gabby Diekmann for her graphic support.
References cited only in Table 1 and Appendix 1