Bridging Health & Community
Bringing Purpose To Community Engagement
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Our Work

Understanding Why Health Care Is Failing

Since 2013 we have looked at why health care is failing communities in difficult social circumstances, such as poverty and exclusion.

By spending time with almost 100 practitioners, we’ve come to appreciate that working with these communities requires starting from their priorities, only one of which is health. We have gleaned 12 over-arching principles for how to do this. Together, they describe an inclusive, participatory and responsive process.

Along the way, we have learned that the process has the potential to foster the ‘agency’ of communities – their ability to make purposeful choices. This ability is core to having a sense of control, which is fundamental to health. In fact, risk factors – whether personal, environmental or social – cannot fully explain why people are healthy or sick. The missing link is whether people have a sense of control. 

We help health care change its way of working to be more inclusive, participatory and responsive.

Not only can this new way of working foster the agency of communities, it also enables health care to reconsider its role with the communities it serves. Health care must move beyond deploying technical solutions for acute illnesses and trauma. It must learn to support people and communities to define and shape their own health. 

But change is always hard. And the change health care must go through is perhaps the hardest – to share power. If it is to share power, health care needs to examine its current and historic role in perpetuating the daily realities of the communities they're part of.

The 12 Principles

The detailed rationale for the principles was included our 2017 report, Fostering Agency to Improve Health. The principles are: 

  1. Include in a community’s collective effort those who live there, those who work there, and those who deliver or support services provided there
  2. Spend time understanding differences in context, goals and power
  3. Appreciate the arc of local history as part of the story of a place
  4. Elicit, value and respond to what matters to community residents
  5. Facilitate and support the sharing of power, including building the capacity to use it and acknowledging existing imbalances
  6. Operate at four levels at the same time: individual, community, institutional and policy
  7. Accept that this is long-term, iterative work
  8. Embrace uncertainty, tension and missteps as sources of success
  9. Measure what matters, including the process and experience of the work
  10. Build a vehicle buffered from the constraints of existing systems and able to respond to what happens, as it happens
  11. Build a team capable of working in a collaborative, iterative way, including being able to navigate the tensions inherent in this work
  12. Pursue sustainability creatively; it’s as much about narrative, process and relationships as it is about resources

Our Products

 Our March 2018 tool helps leaders in health to explore how they can work with communities in a more inclusive, responsive and participatory manner.

Our March 2018 tool helps leaders in health to explore how they can work with communities in a more inclusive, responsive and participatory manner.


 Our March 2018 report describes what we have done over the last 12 months, including our first national symposium, exploring how the 12 Principles can be applied in practice, and sharing our message with health care and health philanthropy.

Our March 2018 report describes what we have done over the last 12 months, including our first national symposium, exploring how the 12 Principles can be applied in practice, and sharing our message with health care and health philanthropy.


Our May 2017 symposium embraced the potential of community agency. A report of the symposium was included as part of our March 2018 report. The full program is available online. Many of the presenters described their work ahead of the symposium (see series). Many of the participants shared their reflections afterwards (see series), and some shared resources and tools. The symposium’s major sponsors were The California Endowment, Kaiser Permanente & the Robert Wood Johnson Foundation.


 Our March 2017 report presented everything we had learned since 2013 through our emerging understanding of the importance of agency to health. It includes a detailed rationale for each of the principles, abstracts of the presentations from the Creating Health Collaborative's 2016 meeting (see below), a series of commentaries on our 2015 report, and a description of the evidence linking agency to health.

Our March 2017 report presented everything we had learned since 2013 through our emerging understanding of the importance of agency to health. It includes a detailed rationale for each of the principles, abstracts of the presentations from the Creating Health Collaborative's 2016 meeting (see below), a series of commentaries on our 2015 report, and a description of the evidence linking agency to health.


 Each July in 2016, 2015 and 2014, we have held an invitation-only meeting of practitioners working with communities in difficult social circumstances. 

Each July in 2016, 2015 and 2014, we have held an invitation-only meeting of practitioners working with communities in difficult social circumstances.