This post was originally published on the Health Affairs Blog on September 23, 2021.

The health and well-being of people are intimately tied to the conditions of life in their communities—conditions that structure opportunities and pathways for lifelong and even inter-generational well-being. Philanthropic efforts to improve community health must attend to the many systems that shape life conditions by focusing not only on whomwhat, or where to fund, but equally importantly, on how to fund.

The Urban Institute’s recent comprehensive review of health-focused community development investments made by the Robert Wood Johnson Foundation between 2013 and 2019 yielded a wide range of insights about how philanthropic investments can drive enduring systems change needed to improve community health, well-being, and equity across the nation.

Drawing on dozens of interviews with grantees and partners, community development intermediaries, and philanthropic leaders; research on collective impact and social accountability; and Urban’s own expertise, we identified three key recommendations (among others) that are especially important to funders seeking long-lasting impacts on community health and well-being:

  1. Target the root causes of community health inequities in the United States by dismantling systemic racism, centering community power and accountability, and investing in children and families;
  2.  Incentivize and pressure the health care sector to redirect significant resources toward community health and development, where so many nonmedical drivers of health and well-being are embedded;
  3. Direct multiple forms of philanthropic power and influence toward true systems change—meaning, permanent imprints on policy and practice—so that power and control are shifted to the people and places most in need.

Three Key Recommendations

The first calls for a fundamental commitment to countering the many systems producing conditions of inequality and health inequities, especially systemic racism and its attendant injustices; empowering—through self-determination and control of needed resources—the people and places most affected by marginalization and exclusion; and investing in the earliest ages and stages of life to allow for the compounding benefits of health-promoting factors over the life course.

Mid-point adaptations to the Strong, Prosperous, and Resilient Communities Challenge (SPARCC)—a multisite initiative involving local efforts in six regions to build healthy communities—included acknowledging racial equity as a primary driver of community health outcomes, and ensuring that community development capital strategies reflect approaches that are community driven. And while it might be tempting to focus exclusively on the people and places that have borne the brunt of systemic marginalization—they are certainly the best positioned to call out how it works and with which pernicious effects—it is essential that we also examine and hold accountable those with more power and privilege, because they generally have the most decision-making control, even at the hyper local level.

A second recommendation stems from the fact that at nearly 18 percent of gross domestic product (GDP) and growing, the health care sector is consuming a disproportionately high share of the nation’s resources. Cross-national evidence consistently shows that the United States spends more on health care (by far) than other high-income countries and yet has among the worst health and survival outcomes. This large and growing “U.S. health disadvantage” spans many decades and is found at all ages, for both sexes, and among all racial and socioeconomic groups.  

The country is not spending its health care dollars wisely, with redistributions needed within the health care system, and equally important, a redirection of some of these dollars out of health care and into other sectors. These include traditional community development areas like housing and the built environment, but also education, employment, and youth development. The Democracy Collaborative, for example, is working with health care system leaders in an effort to proactively address economic and racial inequities in community conditions that create poor health. It is important to recognize, however, that the redirection of health care dollars (at scale and in sustainable ways) into communities will not come without complications or resistance, and philanthropic health funders have a powerful role to play in this shift.

Finally, the many systems that are generating the nation’s large and growing forms of inequality—be it health inequality, income inequality, or wealth inequality—are generally working as designed. It follows that the solutions must also be focused on systems, and in particular, the way they are designed to operate, distribute resources, and confer power.

If we think of systems change in terms of “permanent imprints” on policy and practice, then philanthropic funders should be thinking about how they are contributing to durable shifts in power toward the people and places that have been subject to long-term disinvestment and marginalization. Traditionally, philanthropy has deployed its financial resources through grant making. However, as a significant center of power itself, philanthropy needs to wield all of the resources at its disposal, including its social, moral, intellectual, and reputational capital.

Philanthropy’s Important Role

The opportunities for philanthropy, especially health philanthropy, to improve community health, well-being, and equity are tremendous and still largely untapped. Many efforts across the country are working toward more equitable policies and practices—some are just starting, and others have long and rich histories in their communities.

But it takes power to shift power, and to do so in ways that are both effective and enduring. Health philanthropy can be a major force and accelerator in these efforts, and alongside grantees and other partners, can help shift systems and resource flows in ways that optimize health in underinvested communities across the nation. The country deserves no less.


Copyright © 2021 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.

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