From Savior-Designed to Equity-Empowered Systems

Over the course of hundreds of years, racism was institutionalized into U.S. health care systems, propagating organizational practices and policies that marginalize and discriminate against people of color. Today, institutional racism continues to plague the health of children and families across the country. How do we pursue sustainable change? The answer starts with intentionally confronting and deconstructing how health systems were designed. 

On NICHQ’s recent webinar, From Awareness to Action: Strategies for Combating Racism in Health Systems, experts from the Global Infant Safe Sleep Center shared opportunities to move towards equitable systems. Below, we summarize their advice.

Today’s Disparities Are Not Accidental

In the U.S., people of color face unacceptable poor health outcomes, including disproportionately high rates of maternal and infant mortality. These disparities can be traced to when the first slave ship with Africans landed on U.S. shores in 1619. Over the next nearly 250 years, enslaved people would endure mental and physical violence, poor working conditions, and many other forms of mistreatment—all of which led to poor health outcomes. This violence continued after the Civil War with the advent of Jim Crow laws, which enforced a system of oppression and segregation.

At the same time, racism was shaping the basic infrastructure of the U.S. health care system. During enslavement, African Americans had little to no access to health care; early American hospitals discriminated against and medically abused Black patients; and, during the Jim Crow era, segregated hospitals in many cases provided inequitable care for people of color or no care at all. Moreover, Black people were largely excluded from the medical profession until late in the 20^th century.  

“Our history of segregated care of African Americans, where facilities were established by whites to serve Blacks exclusively, resulted in systems based in unequal power dynamics that resulted in unequal care,” says NICHQ Senior Project Director Stacy Scott, PhD, MPH, who is the founder of the Global Infant Safe Sleep Center. “These hospitals were the foundation for what we’ve termed “savior-designed systems,” which are at the root of many of the disparities we still see today. We’ve made progress to improve these systems in recent years, but we still have a long way to go before we have truly equitable systems.”

To achieve equity, we need to be able to describe the systems that exist and the systems needed to achieve equitable health outcomes.  

By mapping this continuum—by giving each system a name and definition—we can consider where our current approaches have succeeded and failed, and what we need to do to improve, explains Scott.  

Savior-designed systems

Savior-designed systems are originally designed to rescue, save, and deliver services to “vulnerable” communities by members of the oppressing community. These systems:

• do not consider the root causes and institutions that make the population vulnerable in the first place;
• have policies and practices that harm specific racial groups while benefiting others;
• are difficult to navigate by or on behalf of the disparity group; and,
• are impacted by segregation and division, which often results in habits, policies, and institutions that are not explicitly designed to discriminate.

Savior-designed systems devalue individuals’ lived experiences. In response, health care decisions are made without incorporating individuals’ opinions and without considering how racism and oppression have impacted their health and behaviors. As a result, individuals are often blamed for poor health outcomes and labeled as non-compliant, difficult, or rude.

Recent efforts in public health have sought to counteract savior-designed systems by moving toward an ally-based approach.

Ally-designed systems

Ally-designed systems are focused on building self-awareness among the oppressing group while partnering with oppressed groups to spark change. They: 

• recognize that individuals’ unique circumstances and social conditions affect their health, and need to be factored into to health care decisions;
• never use individuals’ circumstances as justification for providing anything less than the highest quality care;
• reflect on lived experience, points of privilege, and oppression to inform additional perspectives needed “at the table”;
• intend to identify and challenge institutional and systematic oppression; and,
• unite with disparity groups who are treated unjustly to create a system dedicated to dignity, respect, and equality.

Ally-designed systems are a step forward, but they still operate from within the confines of white supremacy, explains Avery Desrosiers, MPH, a consultant with the Global Infant Safe Sleep Center. “Bringing people into a project or initiative doesn’t mean there is a shift in the distribution of power and ability to inform decision-making or that new voices are represented fairly. With these systems, the power is still maintained by the ally as the champion of the work.”

Ally-designed systems can then unintentionally feed into paternalism, tokenism, and well-intentioned but one-sided approaches that ultimately privilege “expert” voices over the voices of marginalized groups. Ally-designed systems are a start, but they are not enough.

The ultimate goal: Equity-empowered systems

Truly equitable health care requires purposefully reconstructing systems that are rooted in and advance equity of the historically marginalized group. These “equity-empowered systems”:

• are built and governed to center on the experiences of disparity groups;
• accept racism and other forms of oppression that adversely impact systems of care;
• place specific emphasis on addressing unique needs and root causes of inequitable outcomes; and,
• share power by not only ensuring diverse representation, but also redistributing resources to establish equitable decision-making, design, and implementation processes.

Equity-empowered systems would amplify lived experiences, provide trauma-informed care, and actively name and address the root causes and barriers of navigating challenging systems, says Scott. In short, they would be a catalyst for population-level health improvement.

“Think about these definitions and then think about the systems you operate in,” says Scott “Are they savior-designed, ally-designed, or equity-empowered? What would need to change for your system to shift further along the continuum toward equity?”

Scott and Desrosiers presented this system design information on behalf of the Global Infant Safe Sleep Center on a recent NICHQ-led webinar, From Awareness to Action: Strategies for Combating Racism in Health Systems.