Systems Change is the Change We Need


Bob Hughes, Former President & CEO

Conversation starter: Ask your friends if they feel optimistic about the times that we’re living in and the progress being made. Depending on who you call friends, I think you’ll get a mix of responses. Those not on the receiving end of society’s marginalizations would probably say yes. Those on the other side of the fight, you know, the ones who, for years, have experienced challenges thriving in all aspects of life, would probably say no; no, they’re not hopeful about the future.

While we’re not really in the business of instilling hope (although it happens sometimes), we take our role as a changemaker seriously, with the strategic intention to transform systems and achieve impact for years to come. For MFH, that includes a focus on how people’s actions build and sustain systems. These actions and the systems they produce and maintain have powerful, enduring effects on people’s health. Educational systems, food systems, health care systems, economic systems, public health systems, transportation systems, housing systems, justice systems – decision-makers in all these systems, and others, shape the circumstances of our everyday lives and influence who has fair opportunities to thrive.

Systems can be changed, and if the system is oppressing or not serving all the people, they should be changed. These institutional structures were built and are maintained by people, and people – both inside and outside the systems – can reform them, making them better at providing the conditions for healthy and meaningful lives.

Think about it. In our day-to-day lives, we encounter all kinds of systems – water systems in our homes, electrical systems in our cars – and we are expected to maintain and repair them as needed, including getting experts to help with complicated problems. Social systems, while more complex, need fine tuning as well. But it’s the longer time horizons, and often, multiple tactics necessary to see it through, that make the process much more daunting and easy to ignore – even by those who have the resources and the means. We must avoid settling into a norm in which taking on the work that results in systems change is seen as cumbersome and overwhelming. By doing so we can make real progress.

Take our system of health insurance coverage in Missouri and Medicaid expansion. The U.S. Supreme Court made expansion voluntary for states in a 2012 decision. That prompted many in Missouri to focus on new pathways to get more Missourians covered. Under our Expanding Coverage initiative, a broad-based coalition of almost 1,000 participants – the Cover Missouri Coalition – was formed to maximize resources and improve the health of the uninsured. Partnerships like this are essential to making progress. Mutually beneficial, productive relationships with our community partners are the key to effective combined efforts. And, thanks to our partners, the win we got this year on August 4, that was systems change. In the long run, so many Missourians will be better off and able to access the affordable coverage they need to lead healthy lives. During the years leading up to the vote to expand Medicaid, the Foundation had committed millions of dollars to the cause, working with numerous individuals and organizations across the state so more people would have insurance coverage. It wasn’t a quick fix. Most efforts at systems change aren’t, but once it happens it’s worth it.

COVID has brought the cumulative consequences of systemic racism into sharp relief and has revealed the inequitable racial consequences embedded in our society. Unlike many issues that challenge individual systems to respond effectively, COVID effects the entire country and all our systems. Several recent reports detail the architecture of our housing system, our education system, and the overall effect of multiple systems’ impact on health inequities. Nevertheless, the pervasiveness of these inequities underscores that analysis and education are not enough.  Eliminating the underlying causes of health inequities requires additional tools for people to change these system architectures: advocacy, policy, community power-building, and active resident engagement, to name a few.

Finally, governmental systems at all levels are crucial components of our democracy. They oversee the vital institutions that affect our health. Governments have built in mechanisms for change, like voting, that require thoughtful maintenance and protection to ensure long-term institutional integrity. Unfortunately, these core institutions – from voting to participation in the census – need greater public attention, support, and reaffirmation through widespread participation by all of us. Public will and public institutions are crucial elements of democracy. Sometimes these can be in conflict. Perhaps the best example in Missouri is Proposition 3 on this year’s ballot, the state government’s challenge to the public will that was demonstrated in the passage of Clean Missouri in 2018. This underscores the value of strengthening and safeguarding all the systems – from the post office to polling places – that undergird our most important systems change strategy for democracy (and also the method that brought us Medicaid expansion): the people of Missouri exercising their right to vote.

Why do MFH and our partners focus on changing systems and addressing underlying causes among the many pathways to eliminating inequities? Let’s take a lesson from Medicaid expansion. It may take longer and be challenging, but through constant effort via multiple channels by diverse actors across Missouri, we have fundamentally increased the proportion of Missourians who will have insurance coverage for the foreseeable future. And in the process, this work has demonstrated faith in our public institutions, bolstered Missouri’s health and social sectors, and set expectations for other successful initiatives that can directly improve Missourian’s health for years to come. We are proud to have played a part in this progress and look forward to continuing our work to eliminate underlying causes of health inequities, transform systems, and enable individuals and communities to thrive.