Aligning Health and Social Systems to Promote Population Health, Well-Being, and Equity

Strengthening the integration and alignment of health care, public health, and social service systems is a vital part of promoting health equity and building a culture of health in which everyone has a fair and just opportunity to be as healthy as possible.¹ The need to promote alignment across sectors to address persistent inequities in marginalized populations has become more acute as we face the COVID-19 pandemic and plan for an equitable recovery.

This AJPH special issue, Aligning Health and Social Systems, presents some of the important work that is of heightened relevance in the context of COVID-19. The variety of topic areas and systems involved in the research reflects the breadth of this work. This issue includes articles on such diverse topics as health and housing; health- and social service–spending patterns; aligning funding streams across mental health, criminal justice, and public health; integrating social determinants information into electronic health records; rural–urban differences in multisector public health systems; and links between public health and social service organizations.

The COVID-19 pandemic has challenged the nation in a multitude of ways, including the unprecedented stress it has placed on health care, public health, and social service systems. Never in our lifetime have we seen such a need for these systems to respond rapidly, equitably, and collectively. The economic fallout of COVID-19 will severely affect Americans for years to come, and the same can be said for health care, public health, and social service systems. The pandemic has exposed, in the harshest light, overwhelming inequities in the United States, such as housing instability and cost burden, lack of living wage income, and lack of access to healthy and affordable foods. Inequities in health care—in the form of COVID-19 testing and antibody screening availability, as well as access to medical professionals and hospitals—have never been more obvious. What is the cause of the myriad disparities that we see? Structural racism, other forms of discrimination, and a history of disinvestment in low-income communities and communities of color fuel COVID’s unequal impacts on African Americans, Latinos, Asian Americans, Pacific Islanders, and indigenous people; and sexism amplifies the effects of community closures and the economic downturn on women.

What has become clear in this pandemic is that health care and public health must work together and make appropriate connections to social services that provide housing, transportation, nutrition, income, and education supports. We must look to the alignment of these systems and services as we navigate this pandemic and plan for an equitable recovery. This emerging field can provide evidence and guidance on how to most effectively and efficiently coordinate and align finance and delivery systems across these key sectors to support those most in need. Such alignment and coordination becomes even more important as we anticipate greater need and fewer resources to serve vulnerable populations.

Systems alignment is a core component of a culture of health.² The Robert Wood Johnson Foundation’s (RWJF’s) Systems for Action research program was established to build the evidence base for system alignment through grant support for research to test new ways of connecting the nation’s fragmented medical, social, and public health systems. The program supports scientific studies that evaluate the implementation and impact of novel approaches to systems alignment. As seen in several articles in this issue of AJPH, the system alignment mechanisms studied through Systems for Action take many forms, including shared governance models, platforms for data exchange and integration, bundled and blended payment models, and cross-cutting workforce components such as navigators and integrators.

More recently, RWJF has launched Aligning Systems for Health, a new initiative focused on identifying, testing, and sharing what works to align health care, public health, and social services to better address the goals and needs of the people and communities they serve.³ Specifically, this initiative supports original research and evaluation, the synthesis and dissemination of existing research findings, and relationship building with those already working in the field.

Those working in these and other research programs must now consider how to take advantage of the opportunity that this pandemic has created to plan and implement equitable recovery efforts. The foundation recently released an issue brief titled “Health Equity Principles for State and Local Leaders in Responding to, Reopening and Recovering From COVID-19” (https://rwjf.ws/3fjOHOl) to inform and guide these efforts.

Multisector collaboration between health care, public health, and social services must be at the core of supporting equitable, healthy, and resilient communities during pandemic recovery. The first step is to examine how inequity is a consequence of policies and practices undergirding these systems. Next, recovery efforts should include community engagement so that change is led by those most affected by the inequities. We also need to maintain focus on population health and well-being—but not only on individual clinical conditions, as has frequently been the case in the past. The alignment of financing mechanisms across health care, public health, and social service systems and data sharing across systems need to be at the forefront of all equitable recovery efforts. As we navigate through equitable recovery, we need to test innovations, adaptions in alignment mechanisms, and the integration of service delivery that have emerged out of necessity during the pandemic.

A review of work in systems alignment also suggests a need for future studies to focus on replication and sustainability of successful alignment models. Many promising models of alignment, including those examined in this journal issue, have been tested in only one setting and for relatively brief periods. Differences in community context, popula-tions, and systems can affect whether models that work in one location can be successful in another. Issues of replicability will likely become more important as communities approach and move through pandemic recovery in different ways. Similarly, it will be important to build evidence about successful sustainability strategies that guard against these systems backtracking into silos because of the unprecedented burdens placed on them as well as to identify how they can reinforce and support each other through collaboration, integration, and alignment.

Many of the studies included in this special issue derive from RWJF’s Systems for Action research program, and we encourage readers to consider how these findings can be moved into action in advancing health and health equity across the United States. Key actions to consider include the following:

1. disseminating findings to policymakers and other stakeholders,

2. building evidence about replication, spread, and sustainability,

3. strengthening connections among the implementers of systems alignment strategies to continue to share and build on this work to further the field, and

4. translating systems alignment research for the new context of COVID-19 pandemic recovery and rebuilding.