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Health Equity and the Tripartite Mission: Moving From Academic Health Centers to Academic–Community Health Systems

Park, Brian MD, MPH; Frank, Brian MD; Likumahuwa-Ackman, Sonja MID, MPH; Brodt, Erik MD; Gibbs, Brian K. PhD, MPA; Hofkamp, Holly MD; DeVoe, Jennifer MD, DPhil

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doi: 10.1097/ACM.0000000000002833
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The role of the academic health center (AHC) has traditionally been defined by its “tripartite” mission: to educate the health care workforce, conduct innovative biomedical and clinical research, and deliver high-quality patient care.1 AHCs have historically excelled at the disease-oriented components of this mission, generating novel diagnostic tools, medications, treatments, and experts in subspecialized areas of care.2 This approach has led to meaningful advances; however, the U.S. population continues to have shorter life expectancy and poorer health compared with counterparts worldwide.3,4 These outcomes suggest that substantial obstacles and opportunities remain in AHCs’ emerging focus on population health5,6 and community engagement.7 Such obstacles must be overcome if AHCs are to achieve the Quadruple Aim8 of improving population health, enhancing patient experience, reducing health care costs, and improving provider satisfaction.3,9

Poor health in the United States is widespread yet inequitably distributed, disproportionately burdening communities of color and other vulnerable populations.10–14 The persistence of health inequities despite ongoing biomedical advances has led to a renewed recognition of the vital role that socioeconomic, environmental, and geographic factors have in population health.15,16 A growing body of research demonstrates that “the conditions in which people are born, grow, work, live, and age”17 influence health outcomes far more than medical care.17 Despite the impact of these social determinants of health (SDOH) on individual and population outcomes, the U.S. health care system funnels disproportionate resources into medicine rather than health.18 Inherent, often unrecognized systemic prejudice perpetuates health disparities in a structure that advantages certain populations while disadvantaging others. The impacts of health inequities negatively affect us all,19 hampering our economy and national security by increasing financial waste in health care expenditures and decreasing the number of healthy individuals able to join the military and the workforce.20–23 By one estimate, health disparities cost the health care system $1.24 trillion between 2003 and 2006 alone.10–12,22,24

Though AHCs represent a heterogenous group,25 their shared tripartite missions of education, clinical care, and research26 represent an opportunity to coordinate widespread efforts to address SDOH and health inequities: AHCs graduate approximately half of U.S. medical residents,27 provide about 40% of the country’s hospital-based charity care despite representing only 6% of its hospitals,28 and account for nearly one-third of the nation’s health research funding.29 Despite the potential for AHCs to dramatically impact health inequities, it is unclear what strategies academic medicine should undertake to do so. Reluctance about AHCs attempting to address problems traditionally addressed by other sectors, a clinical reimbursement structure not yet optimized to address population health, and a funding stream that favors disease-oriented research serve as barriers to a coordinated AHC strategy for health equity.2,23,30,31 While efforts are underway to shift financial incentives and increase funding sources, there is increasing awareness that complex, multifaceted contributors to health inequities will warrant multisectoral solutions.20 Given their widespread influence over all aspects of health care, AHCs can play a powerful national role in collaborating with communities across their tripartite mission to achieve health equity. We define communities as “groups of people affiliated by geographic proximity, special interest, or similar situations to address issues affecting the well-being of those people,” such as community-based organizations (CBOs), state agencies, and lay residents.32

Emerging evidence33–35 and national initiatives emphasize the important role AHCs36,37 can play to partner health care with community initiatives to achieve health equity. The growing attention to the impacts of health disparities and the role of AHCs in leading health care innovations calls for AHCs to move their identity toward building academic–community health systems, embedding throughout the traditional tripartite mission a commitment to sharing power, resources, and goal alignment with the communities they serve to advance health equity. Orienting each tripartite mission around community engagement will upgrade AHCs from stand-alone institutions to a network of academic–community partnerships that values multisector community engagement, stays accountable to the community, and sustainably advances health equity. We outline a four-point strategy for AHCs to evolve into academic–community health systems, describing “bright spot” initiatives for each.

Promoting Academic–Community Health Systems

Strategy 1: Cocreate more equitable and inclusive practices for health care workforce recruitment and promotion

In 2016, only 6.3% of medical school matriculants identified as black/African American, 5.1% as Hispanic/Latino, 0.2% as American Indian, and 0.1% as Pacific Islander, with ongoing underrepresentation in these groups within medical school faculty.38–42 These disparities widen as faculty members advance in their careers, with greater disparities noted among professors and health care leadership.43 These numbers stand in contrast to the general population, where 17.8% identify as Hispanic/Latino, 13.3% as black/African American, and 1.3% as American Indian.44 Underrepresented racial/ethnic minorities in medicine also experience higher rates of isolation45 and exclusion than do their nonunderrepresented counterparts.46

Significant disparities exist in health outcomes and quality of care47,48 for racial/ethnic minority patients. One factor may be a lack of diversity in the health care workforce, leading to increased opportunities for biases in decision making and decreased understanding of sociocultural health factors.49 While all health care professionals should be adequately trained to address issues of implicit bias and health disparities, a diverse workforce could be better equipped to problem-solve,50 provide care, educate, mentor, and generate research representative of a socioculturally diverse population.45 Race concordance between patients and providers could lead to improved patient satisfaction, provider engagement, and quality of care.51–53 Furthermore, there is evidence to suggest that racial/ethnic minority providers are more likely to engage in community service,54 mentor other minorities in health professions,55 and practice in underserved communities.45 Finally, industries that prioritize diversity and inclusion, especially within leadership roles, see improved financial performance.56 These findings suggest that the recruitment and retention of a diverse workforce could promote more effective and equitable care delivery.

While limited progress has been made in these efforts,57 bright spots suggest that community engagement plays a vital role, including the following:

  • Cocreating holistic admissions and promotion criteria that account for lived experiences, planning community-based projects, and conducting community-engaged scholarship could elevate community priorities and encourage ongoing partnerships58–60;
  • Increasing pathways to health care professions for underrepresented minorities through partnerships with local schools and CBOs could increase recruitment,61,62 while data monitoring of racial/ethnic demographic concordance between providers and local communities could provide social accountability to communities56;
  • Offering professional mentorship at all stages of training, including mentorship from both academic and community partners, could support a workforce that continues to elevate community priorities in the academic setting.63,64

One specific example of an academic–community partnership is the Northwest Native American Center of Excellence (NNACOE) at Oregon Health & Science University (OHSU). An academic–community partnership among OHSU, Portland State University, and the 43 Pacific Northwest tribes through the Northwest Portland Area Indian Health Board, NNACOE works to improve the health of all people by diversifying the U.S. health workforce with American Indians/Alaska Natives (AIAN) and enhancing tribal–academic partnerships in clinical outreach, education, and research. Strong tribal representation ensures that tribal voices are at the core of all NNACOE initiatives. Evaluation is underway, with promising preliminary results reflected in unpublished internal data, including increasing AIAN learners by over 60% and AIAN faculty by over 16% at OHSU since the program’s inception in 2017.

Strategy 2: Implement curricula focused on equity as a core component of health professions education

Several organizations have called upon health professional schools to emphasize SDOH within their curricula.65–67 These curricula, however, tend to raise awareness of SDOH without empowering learners to take ownership26,68 by changing behaviors in screening for or addressing the SDOH.69,70 Furthermore, specific attention must be given to teach health professionals about inequity-responsive care,71 conveying that the social determinants of equity (SDOE)—the human-made structures that determine how SDOH are distributed (e.g., racism, sexism, ableism)—disproportionately distribute SDOH and health outcomes. Attention to SDOE emphasizes that individual interventions addressing biological and social determinants alone may in fact widen health disparities, as the most oppressed and disadvantaged communities may least benefit from these interventions.26 An inequity-responsive mindset would encourage health care professionals to understand their own societal power and privilege as well as the ways in which health care perpetuates an inequitable system, and would emphasize the responsibility to educate, research, and provide care in ways that interrupt this cycle and support disproportionately impacted communities.71,72 Health professions education should thus provide sessions on power and privilege, inherent bias, systemic discrimination, and geographic distribution of resources, which have demonstrably affected the delivery of more equitable care.73,74

One emerging model for an inequity-responsive mindset involves partnering with and lifting up communities’ expertise regarding the local context of SDOE.66,75,76 Furthermore, it reinforces for learners that communities are experts on the historical contexts and day-to-day impacts of structural factors on local wellness.77 Hiring local experts as community faculty78 allows for contextualization of local and historical impact of race, ethnicity, and culture on health behaviors, enabling providers to deliver culturally responsive care to all groups in the community.79,80 This community context may also protect against the hidden curriculum in AHCs,81 where learners who rotate in urban or underserved areas could begin to attribute certain health conditions and behaviors to social demographics rather than critically assessing the historical and structural determinants that perpetuate inequities.

Formalized structural competency curricula, which focus on these “forces that influence health outcomes at levels above individual interactions,”82 are expanding throughout health professions education. Emphasizing the role of SDOE that produce and maintain health and social inequities, several published structural competency curricula incorporate a cocreation model with local communities, including CBOs, activists, and public health departments,83,84 and are often taught in community-based settings. Early evidence demonstrates promise, with quantitative and qualitative evaluations finding that learners better understand the influence of SDOE,84 feel more comfortable addressing the SDOE,85 and are increasingly oriented toward community-engaged solutions to address the SDOE.84,86,87

Strategy 3: Offer opportunities for our workforce to partner with communities to develop equity-promoting skills

Practical application of skills effectively addressing health inequities with and within the community will require a coordinated, multisector collaboration between AHCs and the communities they serve.20,88 Although medical training disproportionately occurs in AHCs and tertiary care centers, the vast majority of health care is delivered in community-based settings.89 For this reason, community-based primary care settings are uniquely positioned to lead and test innovative academic–community partnerships to address health inequities.90 Moreover, community clinics may be seen by the community as trusted partners, affording them the opportunity to act as a bridge between the larger AHC and CBOs.

The majority of multisectoral collaborations aimed at addressing SDOH fail because of patterns characteristic of some traditional AHC models: short-term grant funding, weak commitment from health system leaders, and lack of patient/resident engagement.91 Given the community orientation of primary care clinics, a commitment to addressing community-specific SDOE and SDOH would require AHCs to financially and philosophically support increasing the numbers and capacity of community-based primary care sites, as they represent one of the fundamental units of the academic–community health system. Patients should be engaged as partners in health, with programs that empower patients—particularly from marginalized communities—to identify their own holistic health needs and cocreate solutions to health. Academic–community health systems would de-emphasize the current paradigm of engaging patients solely through advertising clinical services or soliciting program feedback. Instead, such systems would engage patients and communities in a community-wide interprofessional health care team, thus encouraging neighborhoods to be involved in and lead transformational efforts they identify as essential for health and wellness.92 Flattening the historical hierarchy between the academic and patient communities will require clinics to develop infrastructure that engages community members as partners and follows through on community-powered projects.

Building sustainable partnerships between AHCs, community health centers, and CBOs is a critical strategy for bidirectional learning in an academic–community health system. At Family Medicine at Richmond (FMR) clinic, learners are embedded in a federally qualified health center serving urban underserved patients in Portland, Oregon. FMR is a dues-paying member of the Metropolitan Alliance for Common Good (MACG), a local nonpartisan organization organizing for social change and health equity. FMR and MACG cocreated the Health Equity and Leadership at Richmond (HEAL-R) program at FMR.

Started in 2015, HEAL-R integrates community organizing principles into the patient-centered medical home and centers on the traditionally marginalized voices of communities of color and low-income populations. As a patient-powered, community-led, grassroots program, HEAL-R develops increased socioeconomic opportunities for marginalized communities by providing leadership training and cocreating campaigns that address structural barriers for patients. HEAL-R flattens the traditional provider–patient power hierarchy in health care93 and creates space for patients to drive change, through hosted listening sessions to identify the specific socioeconomic issues impacting patients and their communities. Once patients identify an issue, HEAL-R develops patient leaders to foster civic engagement and build community capacity to create socioeconomic and political change, aligning patients, CBOs, and the health care sector to act collectively for patient-identified social issues. A recent victory highlights the importance of this model: HEAL-R patients identified the lack of affordable housing units as a major contributor to poor health, then partnered with other CBOs and activists to build a successful campaign that raised $67 million for affordable housing in Portland. HEAL-R recently secured funding to expand and evaluate this new program, including its impacts on health care–related metrics (e.g., patient activation measure,94 health care utilization).

Strategy 4: Develop community-based research agendas that support community-based efforts to address inequities

The traditional role of the AHC research mission has been to design and conduct large-scale clinical trials largely confined to academic-affiliated facilities. Despite high numbers of AHCs geographically proximate to marginalized and underserved communities, historical trauma and disrespect for community knowledge at the hands of the health care system have disenfranchised and minimized community voices in research.95,96 More recently, several national organizations, including the National Academy of Medicine, the Patient-Centered Outcomes Research Institute, and the National Center for Advancing Translational Sciences, have emphasized the importance of community and patient engagement in the design and implementation of research projects. This approach represents a notable shift away from advancing individual and institutional research agendas and, instead, toward partnering with stakeholders to ensure that community members both agree with the focus of research and cocreate research agendas. This community-participatory partnered research (CPPR) approach97—a variant of community-based participatory research emphasizing an egalitarian, academic–community model, with communities as equal partners throughout the research process—could pair the community knowledge and research priorities with the health services research resources (e.g., data infrastructure, analytics expertise, institutional review boards) of academic institutions.

Building a robust community-oriented research agenda and community-level database would enhance communities’ ongoing efforts to address local SDOH and SDOE.98 Communities are content experts on the lived experiences of their citizens, whereas AHCs can complement local efforts by offering community-level data and rigorous evaluation methods to assess impacts of community programs, enhance funding proposals, and influence policymakers. AHC leadership can also encourage conditions that promote CPPR by hiring qualitative researchers proficient in CPPR, creating promotion tracks that account for community-based research, and advocating for increased research funding for this work.

Community Partners in Care (CPIC) is a CPPR-based research initiative convening academic and community partners to implement and evaluate community-partnered programs addressing depression in primary care, the highest priority identified by underresourced communities in Los Angeles, California.99–101 Integrating community engagement principles of power sharing and bidirectional capacity building with research principles of scientific rigor, CPIC compared a Resource for Services intervention that offered technical assistance to individual clinics for depression, against a community engagement and planning (CEP) approach of multisector coalition building (e.g., health care, public health, social services, faith-based programs, hair salons) to develop community-wide plans to address depression. CEP significantly reduced the likelihood of poor mental health-related quality of life and behavioral-related hospitalizations102 and addressed patient needs more holistically across the biopsychosocial spectrum. Qualitative evaluations of CPIC demonstrated that participating academic and community partners valued the multisectoral approach, equitable participation, and shared leadership and resources resulting from the CPPR approach.103,104

Sustaining Academic–Community Health Systems

Current approaches to academic–community partnerships traditionally focus on service and outreach opportunities (e.g., patient advisory councils, temporary grant-funded programs) that could disproportionately benefit AHCs, and these approaches have not consistently yielded sustainable or replicable solutions.91 Our strategies for building academic–community health systems restore bidirectional benefits for AHCs and communities, minimizing the perpetuation of existing disparities through inclusive hiring practices, learning and applying inequity-responsive mindsets, and incorporating community agendas in research.

A fully realized vision of the academic–community health system would center each arm of the tripartite mission on advancing health equity with, by, and for the community the system serves, enabling the anchor mission105 of “applying its long-term, place-based economic power and human capital in partnership with its community to mutually benefit the long-term well-being of both.”106 AHCs already contribute $562 billion annually to the national economy107; by proactively recruiting, hiring, and training members of underrepresented groups in the community, AHCs could provide more equitable economic opportunities while also increasing diversity of thought, ideas, and backgrounds. Providing evaluation support for CBOs addressing SDOH for marginalized populations would help dismantle upstream determinants of equity while decreasing rates of costly chronic conditions treated long-term by academic primary care clinics.

Several barriers limit the ability of AHCs to execute this vision: a predominant fee-for-service payment model, a disease-oriented research funding stream, and recent political threats to national agencies historically supportive of health equity programs.108 Opportunities exist, however, for interim steps, including using community health needs assessment findings to guide which CBOs to partner with, and ensuring that hospitals’ community benefit dollars are used to advance community-partnered initiatives.109 Health care professionals can also be critical advocates within health care to speak out against the aforementioned barriers that impede AHC participation in equity work.110 Though AHCs have not always had a consistent definition of their community,29 the neighborhoods of their primary care clinics where the vast majority of U.S. health care visits occur89 represent optimal areas to pursue initial partnerships before scaling up programs.


Given the persistence of health inequities, communities should be engaged for their expertise and lived experiences of health and social disparities in cocreating solutions for health equity. AHCs have a leading role in health care innovation and have a responsibility to partner with communities in addressing these injustices. Though significant barriers exist, bright spots point toward the potential impact of a fully realized academic–community health system vision, one that coordinates collective strengths and resources to advance health equity locally. Our four-point strategy outlines how AHCs can help create not just healthier communities but, in fact, health for all within them.


The authors gratefully acknowledge formatting assistance from Amanda Delzer Hill of Oregon Health & Science University Department of Family Medicine. The authors also thank the following community-based organizations and individuals for their ongoing collaboration, guidance, and mentorship in partnering with the authors as academically based faculty on multiple projects, including CareOregon, Joe Chrastil (and the Industrial Areas Foundation, Northwest Region), Mary Nemmers (and the Metropolitan Alliance for Common Good), the Northwest Portland Area Indian Health Board, the Oregon Food Bank, the Oregon Health Authority’s Office of Equity and Inclusion’s DELTA program, and Senator Elizabeth Steiner Hayward.


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