Communities in Action Pathways to Health Equity (2017) / Chapter Skim
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7 Partners in Promoting Health Equity in Communities
7 Partners in Promoting Health Equity in Communities
Pages 383-446
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These include organizations with a health mission, such as public health agencies, hospitals, or federally qualified health centers. In some communities these traditional partners are joined by public- and private-sector partners, including ommunity-based organizations, faith-based organizations, c businesses (from Fortune 1,000 to small employers)
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These could include combining professional education, joint conferences, new educational tracks within professional schools, and new positions within institutions that span multiple skill sets -- for example, a planner embedded in a health department and a health worker embedded in a planning department. In the following sections, different health equity actors are highlighted, with their unique roles in promoting health equity outcomes described and various examples offered of how they have been able to create partnerships to advance progress toward health equity.
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. The role of hospitals and health system as sources of financing -- for example, through community benefit investments -- is discussed in the section on anchor institutions.
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. Some foundations are also using novel approaches involving community engagement to distribute decision making for program and project funding to the communities themselves.
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Another area for foundation support is civil rights law. A 2001 report to The Rockefeller Foundation on racial justice with findings and recommendations for funders that are relevant in considering community solutions to achieve health equity suggests that • Foundation support is needed to expand civil rights and racial justice lawyering to take on injustice while deepening public understanding of the nature and causes of exclusion, including the complexities of race, ethnicity, and class.
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Recommendation 7-1: Foundations and other funders should support community interventions to promote health equity by: • Supporting community organizing around important social determinants of health; • Supporting community capacity building; • Supporting education, compliance, and enforcement related to civil rights laws; and 1 For more information, see http://www.calendow.org/prevention/health4all (accessed December 19, 2016)
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or promoters of sustainable technology; and through their philanthropic efforts, as funders of a range of activities that may contribute to improving public health. The various ways that businesses can affect health and well-being also illustrate the multiple pathways for business involvement in promoting health equity: through a focus on health care; through workplace wellness and safety; through corporate social responsibility (e.g., sustainability programs, impact investing of education, and other determinants of health)
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The authors concluded that "investments in community health have substantial potential to impact the health of the workforce in these sectors, to narrow occupation-related health disparities among working-age Americans, and to reduce the risk that non-communicable diseases pose to the economic vitality of the nation" (Oziransky et al., 2015)
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a For more information, see https://www.campbellsoupcompany.com/newsroom/news/ 2015/03/23/campbells-healthy-communities-taking-shape-in-camden (accessed October 21, 2016)
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If such efforts are pursued constructively and systematically, business leaders will want to be publicly associated with these efforts because they are viewed as being "good for business." If community leaders and business leaders who are actually concerned about employee productivity, company profitability, and political stability work together effectively, the result will be meaningful improvements that help achieve health equity. ANCHOR INSTITUTIONS Many cities in the United States face significant challenges -- such as high rates of poverty, high unemployment, and substandard schools -- stemming from disinvestment, deindustrialization, globalization, and the related negative impacts on the manufacturing-based economies on which these cities previously relied.
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. Their economic, intellectual, and human capital places anchor institutions in a unique position to improve and enrich surrounding communities in partnership with other key place-based stakeholders from sectors such as government, business, faith, and community-based organizations and local residents.
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have written about the often-conflicting relationships between such large organizations and local communities, particularly when local residents do not perceive their communities to be directly benefiting from the presence of such institutions (Martin et al., 2005; Miller and Rivera, n.d.; O'Mara, 2012)
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have focused on leveraging the economic power of anchor institutions that reside within or next to low-income communities to improve community conditions and the health and well-being of local residents. While many universities and hospitals have community programs as part of their community engagement and community benefit efforts, the NFTAI-proposed anchor institution approach is different.
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Furthermore, the report highlights the importance of shared value and self-interest as motivating forces for anchor institutions to play an active and strategic role in improving conditions in their surrounding communities.
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Examples of Anchor Institution Strategies There are numerous examples of how universities and hospitals have implemented an anchor institution strategy to improve conditions in their local communities, particularly with a focus on the social determinants of health (Rooney and Gittleman, 2015; Rubin and Rose, 2015; Zuckerman, 2013)
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. As noted in the examples below, anchor institutions can and are playing an important role in uplifting community conditions through a series of multilevel strategies and economic investment.
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Reports reflect impressive and significant financial investments by multiple anchor partners, the implementation of institutional changes aligned with the institutional goals noted above, and preliminary indicators that anchor institutions have pivoted in their ap proach through the implementation of major initiatives such as the establishment of three worker co-owned cooperatives, workforce training programs, local hiring practices, and housing assistance programs (ICIC, 2011; Serang et al., 2013; Wright et al., 2016)
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With annual operating revenues of $15.9 billion and assets of $23.4 billion,a the organization returns almost $1 billion to its communities annually in the form of charity care and other community benefit programs. Community health and well-being is central to Trinity Health's mission and to becoming a people-centered health system.
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First, more than $200,000 per year is awarded in pilot grants for innovative programs that address health disparities identified by the community. Second, there is a robust educational program aimed at graduate students, researchers, and community members.
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• Universities, policy centers, and academic publications should modify current incentive3 structures to encour age and reward more research on the social distribution of risks and resources and the systematic generation and dissemination of the evidence needed to guide the com plex, multi-faceted interventions that are most likely to reduce inequities in health outcomes.4 3 Such incentives may include funding, publication standards, and rules governing tenure. 4 SQUIRE (Standards for Quality Improvement Reporting Excellence)
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• How and under what circumstances can researchers and community-based organizers best partner with each other, and what are the most effective community organizing strategies to promote health equity? • What is the role of anchor institution policies and practices, including for colleges and universities, within poor neighbor hoods in contributing to improving community conditions and fostering health equity?
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• Use the required community health needs assessment (CHNA) as an opportunity to pursue health equity issues in a more coor dinated approach with other hospitals and diverse stakeholders committed to advancing health equity (see Box 7-3 for a brief overview of CHNA for charitable hospitals)
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populations experiencing health disparities or at risk of not receiving adequate medical care as a result of being uninsured or underinsured or due to geographic, language, financial, or other barriers."a a Affordable Care Act. Section 501(r)
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The role of hospitals is explored further in the discussion of anchor institutions below. Community health centers and federally qualified health centers (FQHCs)
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. Anchor Institution Approaches Anchor institutions, including universities, hospitals, and other entities discussed earlier in this chapter, that are located in low-income communities have an important role to play in improving local economies and the community conditions that affect health.
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408 COMMUNITIES IN ACTION FIGURE 7-3 Approaches to and drivers of community wealth building to improve economic development. SOURCE: Kelly and McKinley, 2015.
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PARTNERS IN PROMOTING HEALTH EQUITY IN COMMUNITIES 409 FIGURE 7-4 Strategies for building community wealth. NOTE: CDFI = community development financial institution.
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make expanding opportunities to promote health equity in their community a strategic priority. This should be done by: • Deploying specific strategies to address the multiple determinants of health on which anchors can have a direct impact or through multi-sector collaboration; and • Assessing the negative and positive impacts of anchor institutions in their communities and how negative impacts may be mitigated.7 The literature on institutional racism and implicit bias and effects on health equity is generally focused on health care organizations and settings.
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. Examples of faith organizations engaging in work to achieve health equity in their communities include the Health Ministries Association, Inc.
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• where the benefits of public infrastructure -- roads, bridges, transit, and residential and commercial development -- are distributed equitably. This includes opportunities for economic growth, community health, and the increase in wealth that occurs with major transportation and housing or commercial developments.
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Several activities aimed at income and wealth are notable, including health impact assessments related to the impact of "pinklining" on the wealth and future of women (Bhaskaran, 2016) and the need for payday loan reforms (Purciel-Hill et al., 2016)
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. Toward the overall goal of improving the quality of life in northwest Mississippi, QCDO has developed affordable housing, owns a community credit union, provides grants to churches for economic development projects, and engages in a variety of child care social services programs and microenterprise lending.
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As an example, the city of Fresno, California, facilitates the collaborative Fresno Community Health Improvement Partnership to build a Health Priority Index, which looks at places that bear the highest burden of disease and serves as a starting point to think about policy, systems, and environmental change. This multi-sector network uses data as a point of conversation for shared priorities and decision making, bringing together city staff, the public health department, community members, planners, and community-based organizations.9 Centers for Medicare & Medicaid Services Addressing unmet needs in the social determinants of health, such as food, housing, and social services, has gained momentum and interest among payers.
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Public Health Agencies Public health agencies throughout the United States are focusing attention and resources on addressing health equity (e.g., the theme of the 2016 National Association of County and City Health Officials' [NACCHO's] annual meeting, "Cultivating a Culture of Health Equity," and the 2016 Association of State and Territorial Health Officials President's Challenge, "Advancing Health Equity and Achieving Optimal Health for All")
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Public health agencies have the unique ability to use populationbased health data to identify health priorities and health disparities; to inform and help mobilize the community and stakeholders to address health priorities; and to evaluate and monitor the health effects of new policies, programs, and changes to the built environment. Several public health agencies have prioritized addressing health equity in their community health plans (City of Chicago, 2016; OpenData KC, 2016)
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As organizations initiate efforts to address health equity, public health agencies should be engaged in the early phases of plan development. Public health agencies can contribute data, epidemiologic expertise, partnerships, and community engagement capacity in addition to commitments to achieving health equity.
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In addition, public health agencies and health care systems should tap into the expertise of community development organizations (e.g., community development organizations, community development financing institutions) when creating their community health plans.
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. Recommendation 7-5: The committee recommends that pub lic health agencies and other health sector organizations build internal capacity to effectively engage community development partners and to coordinate activities that address the social and economic determinants of health.
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Public health departments, managed care organizations, public health–focused community organizations, and others can serve as partners in assessing health needs and have an influence on educational success. Schools can go further by engaging both district-employed and contracted specialized instructional support personnel, union officials, and other communitybased organizations as part of their efforts to assess and meet student needs, especially those related to health and wellness.
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The Health Impact Project's health impact assessment discusses that data on some community factors already being collected by local public health departments, hospitals, and other agencies and organizations can be examined as part of school-level needs assessments (Morley, 2016)
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Similarly, collecting and analyzing data on absenteeism is an important way to examine opportunities for students to learn. Given the emerging evidence, better data on absenteeism may be critical to addressing health and learning.
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Partnering with law enforcement agencies is essential to building trust between law enforcement and local communities. One mechanism for building trust between law enforcement and local communities is community policing, which is based on the philosophy that police departments can join forces with the communities they serve to determine problems and identify solutions aimed at prevention and intervention (Skogan, 2006)
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. Although civilian review boards were a major focus of the civil rights movement, only some communities successfully convinced local governments to pass legislation establishing civilian review boards, which differ markedly from one another in form, structure, potency, and level of authority (Dunn, 2010; Harris, 2005)
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. Another approach to building collective efficacy involves improving the relationships between community and "external" actors who broker resources for the community, such as banks, politicians, and law enforcement (Vélez, 2001)
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The committee supports the recommendations of The President's Task Force on 21st Century Policing that direct law enforcement agencies and communities toward the creation and maintenance of public safety CROSS-SECTOR COLLABORATION -- HEALTH IN ALL POLCIES The term "health in all policies" (HIAP) refers to the use of a socialdeterminants-of-health approach to solutions and structures that breaks down the siloed nature of government to advance collaboration.
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to inform the development and implementation of a statewide health assessment and community health improvement plan. In 2014 the department released Advancing Health Equity in Minnesota: Report to the Legislature (MDH, 2014)
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Several regions, including Seattle–King County (Washington state) , Nashville, and Atlanta, have implemented cross-sector public sector and public–private partnership approaches to addressing challenges to the well-being of local communities by including a social justice and equity lens in all policies and collaborating to change the local conditions for health (King County, n.d.-a; Minyard et al., 2016; T4A, n.d.)
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Financing and other support for a range of built environment and economic development projects comes from community development organizations. Community development corporations and community development financial institutions manage "billions in housing, real estate and small business assets and investments" and build community wealth and expand opportunities by increasing affordable housing access and building "green" affordable housing (Phillips, 2006)
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As discussed earlier in this chapter, similar efforts to create a public-sector infrastructure for equity more generally or health equity specifically exist in some states and even some local jurisdictions. The National Partnership for Action to End Health Disparities (NPA)
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includes resources as well as an interactive map for monitoring activities by state. • Educate youth and emerging leaders about health inequities and the social determinants of health so that they become champions for health equity: The youth National Partnership for Action to End Health Disparities priority area was developed in response to this need and is preparing young people to become future leaders and practitioners by educating them about health inequities and the social determinants of health and engaging youth in health equity work (NPA, 2016a)
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Facilitate increased coordination at the local level around community health needs assessments through federal funder encouragement and information sharing; 5. Increase collaboration between the National Prevention Strategy, the FIHET, and the Convergence Partnership, a collaborative of national funders and health care organizations working to foster healthier and more equitable environments for all children and families; and 6.
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Sustaining and elevating this crossgovernment effort will be important in helping to galvanize a national effort toward promoting health equity and encouraging ongoing efforts around the country. In November 2016, the president signed an executive order establishing a community solutions council charged with fostering "collaboration across agencies, policy councils, and offices to coordinate actions, identify working solutions to share broadly, and develop and implement policy recommendations that put the community-driven, locally led vision at the center of policymaking" (The White House, 2016)
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. Recommendation 7-7: The committee recommends that key federal government efforts, such as the Community Solutions Council, that are intended to support communities in address ing major challenges, consider integrating health equity as a focus.
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. This executive order builds on and revokes Executive Order 13560 of December 14, 2010, which had previously established a "community solutions council" within the Corporation for National and Community Service, a federal agency, and was intended to be comprised solely of 30 members from outside the federal government and charged "to support the social innovation and civic participation agenda of the Domestic Policy Council" (The White House, 2010)
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. Anchor institutions can play key partner and leadership roles by virtue of their stable presence and economic resource power.
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2013. Universities as anchor institutions.
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pdf (accessed October 20, 2016)
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n.d.-a. Anchor institutions.
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2011. Inner city, anchor institutions and urban economic development: From community benefit to shared value.
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http://isaiahmn.org/vision-3 (accessed October 19, 2016)
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2008. Anchor institutions toolkit: A guide for neigh borhood revitalization.
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2010. Anchor institutions and urban economic development: From commu nity benefit to shared value.
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2013. The anchor mission: Leveraging the power of anchor institutions to build community wealth.
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2016. The role of anchor institutions in restoring neighborhoods: Health institutions as a catalyst for affordable housing and community development.
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