Authority, who holds it, how it’s exercised, and how it evolves, has always shaped human survival. From ancient chieftains organizing defense and distributing resources to modern executives planning billion-dollar hospital networks, authority has been humanity’s scaffolding for coordination.

In healthcare, this evolution is particularly critical. Healthcare is a deeply human system. It heals, protects, and sometimes fails people in their most vulnerable states. As authority structures in society shifted from rigid hierarchies to collaborative leadership models, so too did the priorities and functioning of healthcare institutions. This shift has redefined how we think about service delivery, strategic direction, and health equity.

1. The Historical Roots of Authority in Healthcare

In ancient societies, health was managed through a mix of religious, magical, and communal authority. Shamans, midwives, and herbalists held localized, often spiritual leadership in healing. Their authority was prestige-based, derived from experience and wisdom rather than imposed hierarchy.

As societies grew, particularly with the rise of empires and cities, healthcare became more institutionalized. Authority shifted to royal physicians or centralized religious figures. Ancient Egyptian and Mesopotamian societies had codified health practices overseen by appointed officials, creating some of the first regulated healthcare systems. Here, authority was top-down and formalized.

By the Middle Ages, healthcare was often under the control of religious institutions. Monasteries ran hospitals, and clerics held both moral and operational authority. However, there was limited autonomy for patients or lower-tier healers. This model emphasized hierarchical obedience, not collaborative care.

The Enlightenment and Scientific Revolution catalyzed another shift. Medicine became a profession governed by elite male physicians. Authority now rested in expertise but still operated in exclusionary, paternalistic ways, primarily benefiting white, male, and often affluent patients.

2. Modern Authority: From Paternalism to Participatory Leadership

The 20th century brought monumental advancements in both medical science and social consciousness. With the rise of public health systems, patient advocacy, and civil rights movements, traditional medical authority faced new scrutiny.

2.1 Paternalistic Models and Their Limitations

Traditional healthcare systems operated under paternalistic authority. Doctors knew best, and patients were expected to comply without question. While efficient, this model neglected autonomy, consent, and the cultural context of care.

It also concentrated decision-making among senior administrators and specialists, marginalizing nurses, community health workers, and patients themselves. This rigid structure limited adaptability and trust, especially among underrepresented groups.

2.2 Collaborative and Multidisciplinary Leadership

Today, healthcare authority is evolving into a more distributed model where collaborative leadership is critical. Modern hospitals operate through interprofessional teams. Nurses, psychologists, administrators, and social workers now contribute meaningfully to care planning.

This has:

• Reduced diagnostic and treatment errors through broader input
• Improved team morale and retention, particularly in overburdened systems
• Opened space for patients and families to be part of the decision-making process

The shift echoes our human evolutionary preference for consensual and prestige-based leadership, where those with wisdom and empathy, not just formal titles, gain influence.

3. Strategic Planning and the Evolution of Healthcare Authority

Authority is not just about who gives orders. It’s about who gets to shape the future.

Historically, strategy in healthcare was set by a handful of executives or government officials, often with minimal community input. Strategic decisions, new clinics, care models, or policies were based on financials and top-down data.

Today’s Strategic Evolution

Modern health systems are recognizing that inclusive leadership produces stronger strategic outcomes. This transformation is visible in three key ways:

a. Stakeholder Engagement

Health authorities now consult patients, families, staff, and communities to co-create strategies. This shift builds buy-in, legitimacy, and equity.

For example:

• Hospitals in Manitoba involve staff in risk assessments and planning
• Hospitals in New Zealand include Māori community leaders in system design to reflect Indigenous needs

b. Distributed Leadership

Strategy is no longer confined to the executive boardroom. Clinical leaders, mid-level managers, and frontline providers are empowered to contribute strategic insights.

This enhances:

• Responsiveness to emerging risks
• Innovation grounded in real-world constraints
• Staff retention through ownership of change

c. Values-Driven Decision-Making

With the global emphasis on health equity, ethics, and sustainability, strategy is increasingly values-centered, not just cost-centered.

Executives now lead with ethical authority, balancing budgetary needs with population health outcomes, particularly for marginalized groups. This resonates with the evolutionary principle that leaders must serve the group’s long-term survival and cohesion, not just dominate for personal gain.

4. DEI: Authority Reimagined for Equity

Authority and DEI have had a troubled history. Historically, healthcare systems:

• Excluded women and racialized people from leadership
• Conducted unethical research on vulnerable groups (e.g., Tuskegee, forced sterilizations)
• Dismissed the health beliefs and practices of Indigenous, Black, and immigrant populations

These abuses were possible because of unchecked authority—concentrated power with no mechanisms for inclusion, consent, or accountability.

The Paradigm Shift

The DEI movement in healthcare is essentially about redefining authority—who gets a seat at the table, whose voices shape decisions, and who is believed.

a. Representation in Leadership

Modern healthcare organizations are making tangible efforts to:

• Diversify C-suites and boards
• Recruit leaders from historically excluded communities
• Prioritize inclusive hiring and mentorship pipelines

Diverse leadership changes not just optics but perspectives and priorities. For example, racialized leaders often push for better data on health disparities, culturally competent care models, and equity-centered budgeting.

b. Shared Governance

DEI emphasizes shared power. This includes:

• Co-leadership between clinicians and patients on advisory councils
• Inclusion of community organizations in research and planning
• Respecting cultural knowledge as valid expertise

These are contemporary echoes of prestige-based, collaborative authority seen in tribal systems, where leaders earned influence by uplifting the whole group.

c. Psychological Safety and Organizational Culture

Inclusive authority also reshapes internal dynamics. Leaders today are expected to:

• Create psychological safety where diverse staff can speak up
• Address microaggressions and systemic bias
• Promote transparent accountability

This is part of a broader evolution in authority, from command-and-control to compassion-and-empowerment.

5. Case Study: Evolution of Authority at a Healthcare Institution

Let’s explore a fictional example inspired by common changes seen in progressive healthcare systems across Canada and globally.

Then

Ten years ago, a regional health network operated with a traditional top-down structure. Strategic decisions were made exclusively by senior executives based on financial forecasts and system-wide data. Frontline staff, patients, and community leaders had little to no input in shaping programs or priorities. DEI was not formally embedded in governance, and decision-making lacked transparency.

Now

Today, the same health network has restructured to reflect inclusive, collaborative leadership principles.

• Risk and strategy reviews involve staff from all levels, including medical secretaries, environmental services, and nurse educators.
• The leadership team includes a Director of Cultural Safety and Equity who co-chairs executive planning meetings.
• The network’s DEI committee is supported with funding and authority to guide recruitment, staff training, and service redesign.
• Community advisory councils include Indigenous, newcomer, and 2SLGBTQ+ representatives who inform decisions about new programs.
• A co-designed trauma-informed leadership training was implemented for all management staff, developed in partnership with organizational psychologists and community health advocates.

The result: Service delivery improved across diverse patient groups, workplace culture became more inclusive and responsive, and engagement in change initiatives increased. Leadership shifted from controlling to empowering—demonstrating that authority, when shared ethically, unlocks the full potential of a health system.

6. Lessons from Evolution: Designing Authority for the Future

Looking at human history, the most successful authority systems:

• Reward service over dominance
• Encourage collaborative decision-making
• Foster social cohesion through shared identity and trust
• Adapt in response to group needs and threats

Healthcare, as one of the most complex human systems, thrives when it mirrors these principles.

Implications for leaders:

• Be facilitators, not gatekeepers
• Make room at the table for the most affected, not just the most senior
• See DEI not as a checkbox but as a leadership principle grounded in survival

Conclusion: Leadership That Heals

The evolution of authority, from tribal elders to institutional leaders, reveals one enduring truth: the strongest societies are those where leadership uplifts the group.

In healthcare, this means designing systems where power is shared, diversity is centred, and strategy is driven by compassion and inclusion.

Authority is not about control. It is about building trust, guiding people through uncertainty, and creating systems where everyone thrives.

By honouring our evolutionary roots and embracing our modern responsibilities, we can build healthcare systems and societies, that truly heal.