Building for Impact: The Evolution of Governance in Leading Health Systems
Health systems have spent the past decade integrating a strategic focus on advancing equitable outcomes into their organizational infrastructure, policies, and processes. Data from the Health Impact Alliance’s national survey of health systems offers a peer-to-peer look at how health systems are structuring, resourcing, and governing this work.
Responses from 25 health systems show that just under half (47%) of those with unified health equity departments/offices reported restructuring in the past year, with 65% retaining “health equity” language in their department/office name. The question is no longer whether health systems are investing in equitable impact. It’s whether organizational infrastructure & dedicated resources are durable enough to sustain that investment through leadership changes, margin pressures, and a rapidly evolving environment.
Why It Matters:
Advancing equitable impact is not a self-sustaining endeavor. It requires deliberate organizational architecture—the right executive positioning, the right governance mechanisms, the right resources—to deliver outcomes that outlast any individual champion or budget cycle. Health systems with established infrastructure are better positioned to maintain momentum when conditions shift. This survey is the first opportunity to assess where leading health system approaches stand relative to peer organization.
Three Key Conclusions:
A majority of respondents have established the structural foundation for accountability, with a clear runway to deepen it.
HIA’s Governance Maturity Matrix shows that 59% earn full marks on structural formalization, i.e., having both an organizational home and a formal multi-year strategy. The next step in the maturity curve is extending that foundation into Board & C-Suite/EVP accountability and cross-functional integration, where only 12% of respondents are already operating across all three domains.
The people carrying this work forward are an underdeveloped investment.
Internal staff training represents one of the smallest shares of both operational budgets and grants across participating systems, reporting median allocations of 9.5% and 15%, respectively. Compare that to one of the most reported categories, community-facing initiatives, that claim a median allocation of 40% across both operational budgets and grant dollars. Internal staff training is tied disproportionately to grant dollars, suggesting that the development of people executing on these strategies is dependent on external funding that isn’t guaranteed to last.
Health equity functions have built a strong operational foundation, with room to expand into enterprise narrative-shaping.
Respondents universally lead social determinants of health (SDOH) strategy and clinical disparity gap closure, and consistently drive community-facing, externally oriented work. The next frontier is extending that influence into how the organization tells its story—shaping external communications, communicating value to policymakers, and advancing workforce inclusion practices.
The Bottom Line:
Health systems cannot sustain equitable impact work on programmatic momentum alone. The organizations best positioned to advance this work and reap the benefits over the long-term are not those with the largest teams or the biggest budgets. They are the ones that have built the governance infrastructure for accountability and the resourcing model to sustain through funding shifts. Above all, they have the organizational connectivity to make equitable outcomes foundational to enterprise decision-making.
A snapshot of the survey results (including size-segmented comparisons, a governance maturity matrix, and deeper insights into reporting lines) is available upon request. For questions or to schedule a readout of findings, please reach out to healthimpactalliance@hmacademy.com.