Role of Philanthropy

The philanthropy sector can use different tools to support communities as they design, implement, and evaluate interventions to achieve health equity. In broad categories, these tools include convening, leadership and capacity development, model testing, topic studies and reports, project and program funding, advocacy support, and social movement building.

Convening is a core strategy for foundations, which may serve the role of a trusted, neutral host in bringing together individuals and organizations from different sectors and disciplines. Most foundations aspire to achieve balance and inclusivity across the broad landscape of community members and other stakeholders and to support engaging across differences to achieve a common goal.

Leadership development and capacity building is another commonly used philanthropic tool that helps address gaps, especially within the nonprofit sector, though other private and public sectors can and do take advantage of these foundation programs. In the case of community interventions that are inclusive of multiple sectors and the affected community, funding both the capacity of all participants to fully engage and the development of new leaders within communities is essential to creating enduring change that will outlast the funding duration.

Model testing refers to smaller-scale, innovative interventions that, while based on robust theories and other inputs, may not have the evidence base to attract other funding sources such as local, state, and federal government agencies. Foundations can take risks with innovative programming, fund appropriate evaluation, and create the evidence that others require to address the issues of scale and sustainability. For most of the philanthropic sector, this is as close as philanthropy gets to funding empirical research.

Foundations do fund studies of specific topics: specifically, studies that review and synthesize existing knowledge, projects, or data and create reports, position papers, media, and other products that are intended to support and inspire other work. In fact, this report is an example of what foundations can do to promote community interventions.

Another core foundation strategy for community work involves grants made for explicit projects or programs. Such philanthropic grant making can be responsive (involving a cyclical review of unsolicited grants that advance the mission of the foundation) or directive (usually involving a request-for-proposals process where agencies such as community nonprofits apply to complete a scope of work created by the foundation). Some foundations are also using novel approaches involving community engagement to distribute decision making for program and project funding to the communities themselves.

Advocacy funding may present challenges for certain foundations for which funding issue-specific advocacy strategies, such as lobbying, is prohibited by federal tax law. Nevertheless, such foundations can support advocacy groups with general operating funds (as distinguished from program-specific funds) that can be used to lobby, as long as the foundation is not involved with decision making about what issues the advocacy group chooses to take on. Foundations can also support social movement building by providing support for organizations that use community organizing to address important social issues. However, many (if not most) foundations choose not to offer funding in the advocacy and policy arenas, despite the opportunities to create significant, sustainable change in health equity issues. This pattern may change over time, however, as foundations look for enduring upstream changes in areas that address their mission.

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.
• Civil rights and racial justice lawyering can be a powerful tool to strengthen philanthropic efforts across a range of programs. Creative approaches can help create broader constituencies in various foundation areas, including health, education, and community revitalization.
• Funding for organizational capacity is needed to permit the creation of broad networks and the development of sophisticated techniques.
• Strategic funding of national, regional, and local groups can have a substantial impact. Local groups can work for community solutions around the country while connecting with the broader national civil rights community. Support for problem-solving legal strategies can build trust, build partnerships, and empower community leaders speak for themselves. Lawyers can facilitate access to unresponsive institutions and provide legal leverage against unfair practices. Marginalized communities can use local democracy to challenge structures that isolate and impoverish them (Hair, 2001).

Through greater investments in communities of color and low-income communities, foundations can build on the civil rights movement and advance social justice through advocacy and organizing for structural change (Hansen, 2012; Skocpol, 2013). As an example, while strategic foundation support has enabled the success of the environmental justice movement, funding constraints have made it difficult to build organizational infrastructure, community organizing, leadership development, and effective participation in the policy and legal arenas. Reliable, predictable, and flexible multiyear core support for health, environmental justice, and racial equity organizations is necessary for them to carry out their mission, respond to new challenges and opportunities, and serve their communities (Bullard and Garcia, 2015; Joassart-Marcelli, 2010; Joassart-Marcelli et al., 2011). For a community example of an environmental justice organization that successfully leverages foundation support to build healthier and more equitable communities, see the discussion of WE ACT for Environmental Justice in Chapter 5.

The California Endowment's Building Healthy Communities initiative offers a noteworthy example of a philanthropic multi-sector intervention to achieve health equity. This 10-year, 14-community strategy has, at its 5-year mark, achieved improved health coverage for the underserved, as grantees and partners fought for and supported the successful implementation of the Patient Protection and Affordable Care Act (ACA) and the expansion of Medicaid in California. There has been a stronger health coverage policy for undocumented residents as grantees and partners successfully crafted and led the #Health4All Campaign,¹ paving the way for state-supported health coverage for undocumented children. There have been school climate, wellness, and equity improvements as grantees, partners, and youth have led or supported efforts across the state to reform harsh school discipline and suspension policies, and they continue to work to successfully implement school equity funding formulas. Foundation grantees and partners have lent advocacy support for health- and prevention-oriented justice system reform; a key objective of justice reinvestment is to channel savings from a reduced need for prisons into prevention strategies. Grantees have joined with other coalitions supporting outcome improvement work in young men of color, bringing improved public policy and civic attention to the issue and resulting in the creation of a Select Committee on the Status of Boys and Men of Color in the state legislature. Finally, the Building Healthy Communities initiative has helped grantees in their efforts to enact more than 100 local policies and system changes, ultimately promoting a culture of health in local jurisdictions that emphasizes such community resources as more walkable neighborhoods, fresh food access, park space, and access to safe drinking water.

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
• Prioritizing health equity and equity in the social determinants of health through investments in low-income and minority communities.

Reliable, predictable, and flexible multiyear core support for health, environmental justice, and racial equity organizations is necessary for them to carry out their missions, respond to new challenges and opportunities, and serve their communities. With available tools, philanthropy can play an important role in supporting community interventions to achieve health equity and should be considered as an important potential partner in this work.

Role of Business

The U.S. business community has a significant stake in correcting health inequities as a strategy for stabilizing and strengthening the U.S. economy. Business contributes positively (or negatively) to health and healthy conditions in several ways: as payers offering their employees health care benefits; as employers who have a role in ensuring workplace health and safety; as producers of goods and services that may have implications for health and well-being; as creators of externalities (e.g., causing environmental impacts through such things as the production of greenhouse gases) 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); and through philanthropic endeavors.

Several major U.S. organizations that have addressed employee health for decades, including the U.S. Chamber of Commerce and the National Business Group on Health (NBGH), have in the past several years begun to consider the potential for a wider role for business, beyond workplace wellness and health care insurance, in addressing the social determinants of health and achieving health equity. Analogous to the gradual shift from focusing primarily on health care benefits and how their growing cost affects the corporate “bottom line,” to achieving a better quality of care and better value—including by addressing inequities in health care—there has been an evolution in thinking about worker health and wellness to a greater consideration of the social determinants of health and ways for business to expand opportunity in communities.

Examples of the former include the NBGH Innovation in Advancing Health Equity Award (formerly called the Innovation in Reducing Health Care Disparities Award) and its development of a health disparities cost impact tool and an employer's guide to reducing racial and ethnic disparities in the workplace (Dan et al., 2011). In 2014 a U.S. Chamber of Commerce event entitled Innovations in Workplace and Community Wellness: Navigating the New Terrain included a session titled The Business Case for Equity of Care, in which Kenneth Thorpe spoke about how gaps in equity present “large human and economic costs” and how non-health factors, including community environments, affect health outcomes and the deep inequities among them.

Examples of the latter—the move toward considering what shapes health beyond the factory or office walls—include several high-profile efforts and reports published over the past 2 years. In a report making the business case for racial equity in Michigan, the author writes of the experience of America's Edge and ReadyNation, among other business-oriented efforts to expand opportunity, and concludes that “racially-based obstacles to the success of today's younger generation threaten our economy and security. Tackling these obstacles is not only the right thing to do; it can be a significant driver of our collective social and economic wellbeing” (Turner, 2015). One company that has taken on wellness outside of the office walls is the Rosen Hotels and Resorts, which has shifted its benefits for employees to include college tuition and the construction of a medical center for employees. Rosen has also contributed to funding for a local preschool in a community that was suffering from low graduation rates and high rates of violence.

In 2015 the Vitality Institute published a report that provided support for business leaders' interest in engaging with communities and others to improve health beyond the company walls. The report illuminated the links between an unhealthy workforce and conditions in their communities of residence. It echoed other research in asserting that the limited investment in disease prevention and social programs and services and heavy investment in treatment has contributed to disparities in outcomes. 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). Notably, the report called for employer–community partnerships and recommended that employers “engage in strategic philanthropy and use market-driven solutions to create shared value and address health disparities” (Oziransky et al., 2015). Box 7-1 briefly describes a business–community partnership that seeks to improve community health.

BOX 7-1

Campbell's Healthy Communities Initiative.

Another development in the business sector that can be deployed to engage community-based partners on the topic of collaborative action to improve well being and economic vitality, if not explicitly health equity, is the notion of the triple bottom line (The Economist, 2009): profit, people, planet or achieving balance or harmony among financial, social, and environmental impacts. This notion is conceptually linked with the increasingly popular business sector definition of shared value (Porter and Kramer, 2011) as balancing profit with sustainability and social benefit and the evidence against viewing them as trade-offs (see Chapter 4).

In Capitalism at Risk: Rethinking the Role of Business, Harvard Business School professors highlighted chief executive officer remarks from a series of symposia on capitalism's greatest challenges (Bower et al., 2011). These include executives' concern about societal risks that tear the fabric of public trust, such as income and wealth inequality and its effects—exploitation and political and financial instability. Bower and colleagues observed that “health care costs affect the competitiveness of U.S. businesses but also constitute the leading cause of personal bankruptcy, contributing significantly to the burden of low income,” and they added that, in light of these costs, “it is surprising that business has on the whole been so little engaged with the question” (Bower et al., 2011). Business leaders at all levels understand that poor health reduces business profits, and although they are not necessarily focused on health equity, they are thinking about health and its implications. Bower and colleagues point out that “it is not hard to imagine individual companies, industry associations, or international groups joining in some kind of program to drive widespread attention to these three aspects [smoking, obesity, and substance abuse] of improved health” (Bower et al., 2011). This attention is aligned with acknowledging that smoking, obesity, and drug abuse are the result of health inequities and that in addition to reducing profitability, these inequities widen economic and opportunity inequalities and political polarization that can lead to gridlock and prevent democracy from solving national problems.

To engage local, regional, and national business leaders in addressing health inequities, one effective approach is to discuss the challenges in terms that permit the leaders to participate as partners. This might involve talking about health inequity as weakening workforce productivity, increasing operating costs and hurting profits, and worsening inequality and political polarization. These approaches enable business people to become involved in matters that matter to most to them. Improving health equity enhances the reputations of those businesses involved. 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.

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). These new anchor institution approaches (Andrews and Erickson, 2012; Harkavy and Zuckerman, 1999) share a number of the features noted in the model discussed in this report (see Figure 1-3). For example, their focus is well aligned with upstream approaches relevant to the social determinants of health, such as the creation of workforce training and living-wage jobs with good benefits to increase employment among local residents; building wealth and reducing debt among community residents; creating and improving existing affordable housing; increasing community safety and access to safe green space and parks and affordable healthy food; enriching the presence of and participation in the arts; building advocacy and action capacity among community residents and community-based organizations; and engaging multiple private and public sectors in partnerships.

This new paradigm for anchor institution commitment to improve conditions in their local communities differs from past failed efforts. Such past efforts commonly relied only or primarily on government and foundation grants to universities to develop time-limited projects with their cities and communities without any real integration of the work into their institutional mission, culture, and organizational structure (Taylor and Luter, 2013). Treated as an add-on, these projects were not sustainable and are thought to have contributed little to improving local community conditions (Taylor and Luter, 2013).

For example, the Community–Campus Partnerships for Health (CCPH) is a nonprofit membership organization established in 1997 that promotes health equity and social justice through partnerships between communities and academic institutions (CCPH, n.d.). Members view health broadly as physical, mental, emotional, social, and spiritual wellbeing and emphasize partnership approaches to health that focus on changing the conditions and environments in which people live, work, study, pray, and play. By mobilizing knowledge, providing training and technical assistance, conducting research, building coalitions, and advocating for supportive policies, CCPH helps to ensure that the reality of community engagement and partnership matches the rhetoric (CCPH, 2007, 2012).

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. However, an anchor institution approach is not a panacea, especially if it is not combined with an equitable approach to economic development that meaningfully uplifts the living conditions of long-term, poor residents. Without intentional attention paid to equitable benefits from economic development, such efforts risk contributing to gentrification and the displacement of existing poor residents. Thus, at the crux of anchor institution efforts is the challenge of how to improve community conditions without displacement but instead with observable and measureable indicators that living conditions have improved for the individuals and families living in these neighborhoods prior to reinvestment. The following are community examples of anchor institution approaches to improving community conditions and improving health outcomes. Box 7-2 highlights a few examples of institutions applying the anchor approach.

BOX 7-2

Anchor Institutions: Some Highlights.

Role of Academic Research Centers

One federal strategy to promote the more rapid adoption of clinical research was the establishment of the Clinical and Translational Science Award (CTSA) program, which initially funded 12 institutions (NCATS, n.d.-a). The CTSA program, has grown and evolved over time to more than 60 organizations, but while funding support for community engagement efforts has decreased over the past few years, engaging patients and communities in every phase of the process of translating research into practice remains a program goal. Members of the CTSA consortium collaborated in the publication of community engagement principles (ATSDR, 2011) as well as other products that may be useful to communities, such as logic models (Eder et al., 2013) and suggested measures. A 2013 Institute of Medicine (IOM) report reinforced the critical role of community engagement in all phases of research, from basic research to clinical practice and community and public health research, and concluded that these partnerships with patients, family members, health care providers, and other community stakeholders need to be preserved, nurtured, and expanded (IOM, 2013).

Many CTSA program awardees make resources available to community-based organizations and community members through their community engagement activities. The Irving Institute, funded through Columbia University's CTSA, includes a freestanding community engagement center, the CCPH. From the perspective of university researchers, CCPH supports community-engaged research as well as recruitment and data collection at a convenient place in the primarily Latino community of Washington Heights/Inwood in New York City. However, CCPH also offers resources and services, including free blood pressure screening and meeting space for community-based organizations. (See the description of the community example WE ACT for Environmental Justice in Chapter 5 for information on other Columbia University programs that have fostered local engagement in community research in marginalized neighborhoods of northern Manhattan in New York City.)

Academic organizations funded through the CTSA program (NCATS, n.d.-b) have developed and made available resources that can be used to promote community-based solutions for health equity, such as a health literacy review service and computers for community members to use. The Partnership of Academicians and Communities for Translation (PACT) of the Colorado Clinical & Translational Science Institute includes the PACT Council, which comprises 18 members with equal representation from the university and community, with participants from more than 20 ethnic, geographic, and self-identified communities facing a range of health disparities (Westfall et al., 2013). Two activities are particularly relevant for community-based solutions to achieve health equity. 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. This includes a seminar series on community engagement as well as the Colorado Immersion Training program, which provides an intensive longitudinal experience for researchers to develop and sustain community-engaged research, including a placement in a local community.

As noted in Chapters 3 and 4, respectively, transdisciplinary research approaches are needed to produce more of the evidence necessary to inform work on health equity, and the knowledge base that communities can draw on today to design solutions to reduce health inequities is not well matched to the challenge (i.e., randomized controlled trials are not a good fit for generating evidence on approaches that address the social, economic, environmental, and structural factors that shape health). An increased knowledge base could inform and guide communities in applying the promising strategies needed to shed light on systems and how to change them, to increase the understanding of complex and interacting initiatives aimed at population-wide change, and to support the work of continuing adaptation to improve outcomes. Yet, longstanding traditions and institutional arrangements have favored a narrow swath of research—research using controlled experimental methods to identify circumscribed programs that have been found to be effective in controlled settings. Therefore, based on the committee's expertise and its examination of the available evidence, the committee recommends the following:

Recommendation 7-2: A number of actions to improve the knowledge base for informing and guiding communities should be taken, including

• Public and private research funders should support communities and their academic partners in the collection, analysis, and application of evidence from the experience of practitioners, from leaders of community-based organizations, and from traditionally underrepresented participants who are typically left out of such partnerships.
• Universities, policy centers, and academic publications should modify current incentive³ structures to encourage 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 complex, multi-faceted interventions that are most likely to reduce inequities in health outcomes.⁴
• Academic programs should promote the development of and dialogue on theory, methods, and the training of students to create a more useful knowledge base in the next generation of researchers on how to design, implement, and evaluate place-based initiatives to improve community health.

Regarding the final bullet in Recommendation 7-2, such programs would contribute to preparing population health researchers and practitioners to advance knowledge that leads to improved population health science. These future researchers will need to address several questions, such as

• Through which modifiable mechanisms do community-level factors affect health directly and indirectly? And for which populations and what health conditions?
• Which policy and community-level levers are the most powerful, feasible, and sustainable for improving health in varied community settings—and for what health conditions?
• What have been promising approaches for place-based interventions, and what methodological challenges have they faced in documenting change at the population level and scaling up?
• What is the role of social capital, collective efficacy, community organizing, and the empowerment of community residents as agents of change for improving community conditions in place-based interventions? And what effective or promising approaches have been used?
• 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 neighborhoods in contributing to improving community conditions and fostering health equity? What are the pros and cons of various campus-community partnership models? What evidence exists regarding the efficacy and impact of these partnerships on the factors that affect health and health outcomes among local poor communities? (Smedley and Amaro, 2016)

Hospitals and Health Systems

Hospitals and health care systems share in the responsibility to improve health equity. The American College of Healthcare Executives, the American Hospital Association (AHA), America's Essential Hospitals, the Association of American Medical Colleges, and the Catholic Health Association of the United States have urged all hospitals to “take the #123forEquity Pledge to Eliminate Health Care Disparities” (AHA, n.d.-a). The AHA provides a tool kit (AHA, 2015) and other resources (AHA, n.d.-b) for hospitals that pursue the #123forEquityPledge.

In a review of the literature and interviews with leaders of health care organizations, the Institute for Healthcare Improvement (IHI) outlines practical steps and a conceptual framework for guiding health care organizations that want to begin a journey to improved health equity. The IHI stresses the importance of “making health equity a strategic priority at every level of an organization, especially at the top” (IHI, 2016, p. 4) and outlines a number of concrete ways for health care systems to get started. The paper offers a framework for change and a self-assessment tool for health care organizations to assess their current state on each component of the IHI framework. In the IHI and AHA materials, hospitals are urged to start their health equity journey by looking at practices within their own institutions, with the stated goal of “dismantling the institutional racism and implicit biases that hold us back” (IHI, 2016). The AHA equity-of-care tool kit highlights the steps that hospitals can take—starting with leadership—including better collection and use of data on race and ethnicity, cultural competency training, and increasing diversity in governance and leadership (AHA, 2015). Key components of the IHI framework are outlined below:

• Begin quality improvement work by considering the needs and issues faced by populations experiencing worse health outcomes and the greatest disparities in the social determinants of health.
• Tailor quality improvement efforts to meet the needs of marginalized populations across the continuum of social determinants of health.
• Include traditionally disenfranchised people in health care transformation efforts and in advisory positions.
• Use the required community health needs assessment (CHNA) as an opportunity to pursue health equity issues in a more coordinated 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).
• Provide cultural competency education within the institution and in the community.
• Procure supplies and services from women- and minority-owned businesses and use hiring practices that promote diversity and inclusion; increasing diversity in hospital leadership and governance is especially important.
• Increase access to health care and human services which includes, among other things, building health care facilities in underserved communities.

BOX 7-3

Community Health Needs Assessment.

Hospitals also need to commit to looking beyond the walls of their institutions to address the root causes of poor health that are situated outside hospitals; the primary causes of growing health disparities in the United States do not begin in a doctor's office, and place heavily influences health (see Chapters 2 and 3). To truly advance health equity in the community, hospitals must also have a strong focus on improving the places where people live and work and where children learn and play.

Hospitals are well positioned to help lead multi-sector work aimed at advancing health equity. For example, hospitals are often trusted health leaders in the communities they serve. Nonprofit hospitals are already required to conduct CHNAs (see Chapter 6), a task that could be conducted with a health equity focus. For example

• Bon Secours in Baltimore and Virginia has partnered with community organizations to develop low-income housing.
• Catholic Health Initiatives, a health care system based in Denver, requires all of its hospitals to address one community-identified issue related to violence prevention.
• Our Lady of the Lake Hospital in Baton Rouge has a robust program of school health clinics that includes physical, dental, and mental health. The purpose of the program is to improve school attendance and to ensure that children are ready to learn.
• Presence Health in Chicago is partnering with Catholic Charities and others in the community to form an accountable health community and will be identifying and addressing issues related to social determinants.
• Innovations in the use and sharing of data are increasingly used to bring partners together across the social determinants of health to highlight connections, create a common language, and monitor progress across various sectors (e.g., see the Camden Coalition of Healthcare Providers⁵).

Moreover, as anchor institutions, hospitals are deeply rooted economic engines in the communities they serve, holding significant social capital and controlling vast amounts of real estate and other financial investments (see the section on the role of anchor institutions in this chapter). By leveraging their economic power, good will, and human resources, hospitals can make significant advancements in health equity. The role of hospitals is explored further in the discussion of anchor institutions below.

Community health centers and federally qualified health centers (FQHCs) have long played a role in providing primary care services to underserved populations, including uninsured and underinsured individuals and families (for a summary of the first rural FQHC, Delta Health Center, see Chapter 5). A 2010 report on FQHC partnerships with local health departments described “promoting health equity and eliminating health disparities” as one goal of such partnerships (Zakheim et al., 2010).

In 2015 the National Association of Community Health Centers (NACHC) implemented the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE), a national effort to help health centers and other providers collect the data needed to better understand and take action on their patients' social determinants of health.⁶ The PRAPARE Core Measures include, in addition to race, ethnicity, and education, housing status and housing stability, migrant and seasonal farm worker status, material security, transportation, social integration and support, and stress. The PRAPARE tool is being used with different electronic health record systems and in different settings (NACHC, n.d.-b).

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. The anchor institution approach of an articulated mission, strategies, and metrics to improve community conditions has gained increasing attention and buy-in in a number of major metropolitan areas. Such organizations have made significant investment, usually with a number of other anchor partners, including city government and, often, private investors. Data on how such efforts have improved the living conditions of long-term and poor residents are not yet available.

Yet, a number of the anchor investment areas have evidenced gentrification and displacement, and often local residents question whether long-term and poor residents have benefited compared to the benefits gained by anchor partners and wealthier residents who have moved into the areas. Thus, while anchor investment areas are promising, a major remaining challenge for anchor institutions is whether in fact they can improve the quality of life for low-income residents in their surrounding neighborhoods. This will require keeping a careful eye on the development of community initiatives that equitably benefit long-term and poor residents of their surrounding communities.

An alternative to the traditional approach to economic development described by the Democracy Collaborative focuses on community wealth building (Kelly and McKinley, 2015). Figure 7-3 shows the drivers of community wealth and the differences between traditional and community wealth-building approaches to economic development. Figure 7-4 shows six strategies for the wealth-building approach. The wealth-building approach does not assume that economic development will result in “trickle down” benefits to local residents and instead employs and builds on existing assets within the local community to build sustainable ecosystems that promote equity and provide direct benefit to local residents. This is the real distinction between wealth-building and more prevalent market-driven approaches that can be part of more traditional anchor approaches to development.

FIGURE 7-3

Approaches to and drivers of community wealth building to improve economic development. SOURCE: Kelly and McKinley, 2015.

FIGURE 7-4

Strategies for building community wealth. NOTE: CDFI = community development financial institution. SOURCE: Kelly and McKinley, 2015.

The concept of shared value discussed above also offers another approach to the traditional anchor approaches to community and/or economic development. Porter (2010) has described how anchor institutions should view community viability as a critical driver of an anchor's long-term success in workforce hiring, recruitment, and quality of life, and asserted that when anchors make progress working with communities with the greatest need, that can help create “the greatest shared value” (Porter, 2010).

Conclusion 7-1: Based on its judgment and its review of community-based efforts to promote health equity or address the determinants of health, the committee concludes that community-based innovations are often most effective when they build on efforts of various community entities (e.g., foundations, anchor institutions) with an existing foundation or body of work and a strong presence in the community.

Recommendation 7-3: The committee recommends that anchor institutions (such as universities, hospitals, and businesses) 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. Little or no evidence is available for other kinds of anchor institutions (aside from scholarship on racism and bias in academia, although not as anchor institutions or in the context of the production of health inequities). Based on the evidence and examples available from health care, however, and with the support of emerging tools on equity, diversity, and inclusion,⁸ anchor institutions could develop a structure and processes to identify and decrease institutional racism and implicit bias within their own institutions to enable them to evaluate their roles and engage with communities more effectively.

The Role of Faith Organizations

Faith organizations are often a key partner in advocating for and developing or providing health care services as well as in addressing the social determinants of health. Faith organizations are often the entities where issues are first identified at a point when they can be dealt with at a much earlier and resolvable stage. A community of caring and competent volunteers can be mobilized to address the community's needs and to advocate for appropriate legislation and the use of civic resources—including food, shelter, pregnancy care, child care, respite, elderly care, and addiction care—to address health equity (e.g., see a summary of work by ISAIAH, a faith-based community organization, in Box 7-4). Health care providers can be a partner and resource for the many faith communities in their service area. Whether for dental care, opioid addiction, advanced care planning, or domestic abuse, partnering with faith communities can be invaluable, as they often have the most confidence of and credibility with their communities (Schroepfer, 2016). Examples of faith organizations engaging in work to achieve health equity in their communities include the Health Ministries Association, Inc. (HMA, n.d.), the Maryland Faith Health Network (Health Care for All, n.d.), and the Methodist Healthcare Center of Excellence in Faith & Health (Methodist Healthcare, n.d.).

BOX 7-4

ISAIAH: Improving the Health and Wealth of Minnesotans through Grass Roots Organizing and Strategic Partnerships.

Almost all faith organizations are clear that in addition to preaching the doctrines of their faith, a critical call is to provide service for those in need and those most vulnerable. With their unique position in the community, they have the ability to be invaluable in achieving health equity.

Community Development Corporations

Community development corporations (CDCs) are nonprofit, community-based organizations focused on revitalizing the areas in which they are located, which are typically low-income, underserved neighborhoods that have experienced significant disinvestment (Democracy Collaborative. n.d.-b). The CDC movement is 45 years old, and the Democracy Collaborative reports that more than 4,000 CDCs across the United States engage in a variety of communities, including those with high proportions of racial and ethnic minorities (Democracy Collaborative, n.d.-b). Historically, the emphasis of CDCs has been housing, but today the functions and services of CDCs vary widely, with some also offering direct health services. The work of the Thunder Valley CDC, for example, is summarized in Chapter 4. Additional examples below highlight the variety of CDC activities taking place.

Chicanos Por La Causa, Inc. (CPLC) is one of the largest Hispanic CDCs in the United States (CPLC, n.d.). For more than 40 years, CPLC has focused on building stronger, healthier communities by providing the political and economic empowerment that supports individuals to learn the skills and develop the resources necessary to become self-sufficient. Funded through a grant from the Helios Education Foundation, a new program in Arizona focuses on helping 2,000 Hispanic parents develop literacy and advocacy skills related to education and health services. Through the Northern New Mexico Food Hub, Siete Del Norte, a subsidiary of CPLC, is working with community partners to assist local farmers to access commercial markets and make local produce more readily available in rural New Mexico. Health services are provided through multiple CPLC components.

Since 1975 the East Bay Asian Local Development Corporation (EBALDC) has invested more than $200 million in assets in Oakland and the greater San Francisco East Bay area with a primary emphasis on housing options, social supports, and income and wealth (EBALDC, n.d.). Recently, EBALDC has developed and implemented a healthy neighborhood framework for assessing each potential project, program, and partnership for its potential to bring resources and opportunities that will enable the people who live there to make choices that lead to healthy and vibrant lives. This healthy neighborhood framework also informs assessments of the needs of particular communities as well as the particular approaches to be applied. While the primary emphasis areas remain consistent across activities, special attention is focused on other needs of the community, based on the assessment. EBALDC's work will be complemented by collaboration with local businesses on nearby commercial corridors to improve the business environment, create good jobs, and support business development in the neighborhood.

The Quitman County Development Organization (QCDO) was established in 1977 by a group of African American community activists with a history of engagement in the civil rights movement (QCDO, n.d.). 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 micro-enterprise lending. A number of activities target early childhood. For example, the Raising a Reader program targets children 3 to 5 years of age to assist with early language development. In addition, the program equips parents with the skills and knowledge to successfully support their children's growth in reading and language through monthly parent meetings, monthly classroom readings, the provision of books for reading to the child, and parental tracking of books read to the child.

Policy Makers and Elected Officials

Policy makers may be elected officials such as members of city councils or of municipal, county, or school boards; state legislators; mayors and governors; members of Congress; and the president of the United States. Policy makers also include policy and other staff at different jurisdictional levels and in different types of agencies and departments. Policy makers in a specific sector range from the local (e.g., zoning) to the national policy level (e.g., implementers of the Fair Housing Act).

Local policy decisions may have untoward effects that create conditions that contribute to health inequities. The IOM identified the role of policy as a determinant of health in its report For the Public's Health: Revitalizing Law and Policy to Meet New Challenges (IOM, 2011). The report provides examples of various policy decisions across sectors that can have impacts on health. For example, land use decisions can shape the physical environment (e.g., building freeways that divide neighborhoods) and agricultural policy can impact the food environment (e.g., corn subsidies contributing to poor diets) (IOM, 2011). There is also research that suggests that policy decisions can have a disproportionate impact on underserved populations. Fullilove and Wallace (2011) examine historical policies such as segregation, redlining, and urban renewal and their effects on minority populations. The displacement of these groups has been linked with violence, family disintegration, substance abuse, sexually transmitted diseases, and stress (Fullilove and Wallace, 2011). The committee finds that policy makers, discussed throughout the report, can play a significant leadership role to promote health equity.

Recommendation 7-4: The committee recommends that local policy makers assess policies, programs, initiatives, and funding allocations for their potential to create or increase health inequities in their communities.

Policy makers and government executives can help spur innovations in connecting the dots for health equity, as in the case of geospatial data that can highlight associations. 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. For example, the Centers for Medicare & Medicaid Services recently developed an innovation project, “accountable health communities,” that required screening patient populations for unmet needs and referring them for services. Participating health care institutions were required to demonstrate linkages with local resources and joint planning. As part of the program, a common screening tool will be developed. A broad social-determinants-of-health lens would require comprehensive screening across many areas, including housing, food security, employment, transportation, and education. It would also elicit consumers' desire for assistance. Various tools along these lines have been developed in pediatrics.

Some evidence-based models exist that rely on screening and referral. In addition, there are pediatric models that embed intervention services related to social determinants of health (reading, early childhood education, and advocacy) within clinical settings. At times the referral is combined with dedicated staff, such as community health workers, patient navigators, or case managers, who refer and also facilitate linkage with available community programs (Shah et al., 2014). One challenge with broad screening programs is that they require maintaining up-to-date program and contact information for local private and public agencies. Another is the need to provide training at the screening site concerning sensitive screening, avoiding stigma, and broadening knowledge across the areas of need. Finally, screening programs can fail if resources in the community are not available to address identified needs, leading the screening to be both inefficient and ethically questionable.

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”). Addressing health equity will require the intentional investment of resources and support in the communities and populations with the greatest need. This approach is not new to state and local public health agencies accustomed to using infectious disease data to guide their investments in prevention and treatment measures to the highest risk individuals and communities. As an example, the number of newly diagnosed HIV infections decreased 19 percent from 2005 to 2014 (CDC, 2014), and reductions in the morbidity, mortality, and health care costs associated with vaccine-preventable diseases from 2000 to 2010 have been included among the top 10 public health achievements for the decade (CDC, 2011). Public health agencies are working to adapt such approaches to address the non-health factors that shape health outcomes, including education, transportation, housing, and employment opportunities, and to exchange data with the traditional and nontraditional partners that are primarily responsible for addressing these social and economic factors. In addition, public health agencies will need to access other, nontraditional public health data sources on the social determinants of health as they continue to work in this area. Data on indicators such as high school graduation rates, poverty levels, affordable housing availability, median family income, unemployment rates, and limited English proficiency could be considered core public health data.

Public health agencies have the unique ability to use population-based 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). In March 2016, the Chicago Department of Public Health launched Healthy Chicago 2.0, a citywide plan that was developed and will be implemented in collaboration with representatives of more than 130 organizations across a broad range of sectors with the primary goal of achieving health equity (City of Chicago, 2016). NACCHO has developed a health equity and social justice program¹⁰ to build the capacity of local health departments in confronting the root causes of health inequity, including resources such as a tool kit and a Web-based course for the public health workforce (NACCHO, 2016).

Because of existing relationships, public health agencies may be the natural conveners of certain health equity stakeholders, including health care systems, community organizations, and health insurance companies. They can also be partners with or conveners of community development organizations, faith-based organizations, businesses, and other governmental agencies (e.g., transportation, housing, education) because public health agencies have the data needed to link nontraditional partners' work and interests to health and to share with them evidence-based approaches. Box 7-5 highlights a few examples of public health agencies as conveners or partners. In recent years, due in to part to the evolution of public health accreditation standards (PHAB, 2013), many public health agencies have invested in the staff and training required to support community engagement for addressing acute or emerging health issues as well as ongoing public health priorities. Some innovative public health agencies have even invested in staff who can provide capacity building assistance to communities too.

BOX 7-5

Public Health Agencies as Conveners or Partners.

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.

Public health agencies can hire staff who have community development knowledge and experience. 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.

As local jurisdictions start to come together to address the underlying social determinants of health, many of the legacy structures that continue to influence social issues will need to change, and change, although disruptive, can lead to greater effectiveness. In both Boulder, Colorado, and San Diego, California, housing and health departments have come together in recognition that health equity is difficult to achieve if homelessness or housing insecurity is a major issue (Quinn, 2016). Creating new ways to provide services is not only achievable through merging departments to create a more efficient system; it can also happen through how funding is allocated toward improving conditions related to the social determinants of health. Lead poisoning, poor housing conditions that exacerbate asthma, and physical risk from poor housing structures are physical environment factors that directly affect health and that disproportionately affect the health of vulnerable populations. The funding streams available to remediate such a problem can be complicated to apply for, and often there is a need to go through several funding sources and applications. Although there are co-benefits from retrofitting a house (e.g., energy efficiency, better health from addressing asthma triggers), funds are separated even if the retrofit achieves multiple benefits. The Green and Healthy Homes Initiative has been able to braid funding from federal, state, private, and philanthropic partners to address housing and health issues in a more holistic way (GHHI, n.d.). For a community example that addresses housing and health with a multi-sectoral approach, see the discussion of People for Sustainable Housing in Chapter 5.

In early 2016 the Governance Institute convened the first in a series of intensive trainings as part of Alignment of Governance & Leadership in Healthcare: Building Momentum for Transformation. The training, which will recur, was designed to orient health care delivery system executives to the potential of interfacing and partnering with the community development sector. Moreover, the Build Healthy Places Network, the Center on Social Disparities in Health, and the Robert Wood Johnson Foundation (RWJF) have put forward “Making the Case for Linking: Community Development and Health,” a brief highlighting multiple models and examples of health and development sector partnerships from around the country (Edmonds et al., 2015).

Recommendation 7-5: The committee recommends that public 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. They should also play a convening or supporting role with local community coalitions to advance health equity.

The Role of the Educational System

Schools and school systems have not typically thought of public health and health care professionals as potential partners in their efforts to confront the nonacademic aspects of low educational achievement, especially in the context of their required efforts to conduct needs assessments and develop school improvement plans. However, there are many potential stakeholders on which schools could rely for advice and support. 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 community-based organizations as part of their efforts to assess and meet student needs, especially those related to health and wellness.

Community engagement and the partnerships that may emerge as a result are likely to affect educational outcomes as well. There are numerous examples of schools where well-conceived and well-coordinated partnerships appear to have affected both the physical and the mental health needs of student and academic achievement (Frankl, 2016). Although the strength of the evidence underlying these examples varies widely, as does the scale of these partnerships, there is reason to believe that the observed positive educational effects are related to the care with which these partnerships have been built (Freudenberg and Ruglis, 2007). High-quality community engagement is essential across all grade levels—early childhood, elementary grades, and high schools (ICF International, 2010; Legters and Balfanz, 2010; Sigler, 2016). Engaging low-income families is challenging for a variety of reasons, not the least of which is that all too often these are people who have had negative experiences with schools and school systems (Mitchell, 2008). Other factors range from logistical issues associated with the parents' or guardians' ability to get to schools, to social and cultural factors having to do with their ability to effectively navigate the organizational dynamics of schools, especially for schools that are not deliberately focused on family involvement (Hornby and Lafaele, 2011). See the description of the Eastside Promise Neighborhood in Chapter 5 for an example of a low-income community that seeks to improve both health and educational outcomes.

Another approach to the role of schools in health equity interventions is to address education and health disparities by focusing on health problems that are widely present in communities, for which there are strong linkages to academic success, and for which community-based intervention is possible. Basch suggests that it is important to think in terms of causal pathways, plausible explanations for why a particular health problem would cause a negative educational outcome (Basch, 2011). He identifies a variety of educationally relevant health factors, ranging from vision impairment, asthma, and dental disease to aggression and violence, nutrition and obesity, and sexual health issues, which taken together are likely to negatively affect educational opportunities and learning outcomes.

Collecting data on health determinants and health indicators as part of local needs assessments would help in the identification of health problems that affect student learning and achievement. The Every Student Succeeds Act¹¹ is a new federal mandate that requires school-level needs assessments, although access to quality data may persist as a barrier. A forthcoming health impact assessment conducted by the Health Impact Project (a joint initiative of the RWJF and The Pew Charitable Trusts) highlights the need to collect student-, household-, and community-level data on social determinants of health that influence student achievement (Morley, 2016). Unfortunately, not all schools have good data on chronic absenteeism, for example (Balfanz and Byrnes, 2012). Nor is information on school climate and neighborhood or on the community factors that affect learning widely available. 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). Inclusion of such data in the development of school improvement plans can help to identify and build community partnerships beyond school settings to further improve student health and academic achievement as well as school performance (Morley, 2016). See Chapter 6 for a recommendation (Recommendation 6-2) on state department guidance for student health needs assessments.

Household and community factors figure prominently in educational outcomes and could be addressed through community-based education efforts. Neighborhood and household poverty have effects on the social, emotional, and physical resources available to children. Research indicates that violence gives rise to higher risks of posttraumatic stress and negative effects on school functioning (McGill et al., 2014). Housing instability creates attendance problems as well as affects the ability for sustained exposure to specific teachers and schools. Child welfare policies often exacerbate discontinuities in schooling. Other factors being equal, the more these neighborhood and household factors can be understood and addressed in concert with school efforts, the more likely it is that both health and educational outcomes will improve.

Mounting evidence suggests that focusing on measures of student engagement—especially those that have to do with sense of self, self-regulation, social awareness, and self-efficacy—both foster a sense of wellbeing in students and promote learning (see Dweck et al., 2014; Miyake et al., 2010). However, schools will need to broaden how they currently think about success for these measures to make sense. Schools might also have to adopt new data collection strategies, such as student and parent surveys, to generate this type of information. The CORE districts, a network of urban school districts in California, have developed such an instrument to collect data on factors they view as important indicators of student success (CORE, 2016).

Focusing on measures of school conditions may be another way to generate information about emotional well-being and learning. The research base about school climate and culture is substantial and suggests that in addition to leadership and instructional coherence, strong and trusting relationships among adults and between adults and students matter greatly to school and student success (Bryk et al., 2010). This, too, might require extra effort for school officials, but, given the evidence, it offers great potential in terms of improving the conditions for learning and student well-being. A School Quality Review Guide for the New York City Public Schools includes survey data on New York City schools' climate and culture (NYC Department of Education, 2016).

Measuring suspension and expulsion rates would give schools a sense of whether their disciplinary policies are excluding students from learning opportunities. 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. Irregular attendance is often a function of underlying health factors and is correlated with credit accumulation in middle and high schools (Balfanz and Byrnes, 2012). Children who are chronically absent in the early grades are much less likely to read at grade level, and whether a young child reads at grade level in turn predicts academic performance at the middle and high school levels (Chang and Balfanz, 2016; Ginsburg et al., 2014). See Chapter 6 for more on the role of education at the federal and state levels.

Recommendation 7-6: Given the strong effects of educational attainment on health outcomes and their own focus on equity (ED, 2016), the U.S. Department of Education Institute for Educational Science and other divisions in the department should support states, localities, and their community partners with evidence and technical assistance on the impact of quality early childhood education programs, on interventions that reduce disparities in learning outcomes, and on the keys to success in school transitions (i.e., pre-K and K–12 or K–12 postsecondary).

Providing federal assistance to advance early childhood education programs is likely to provide many benefits for health equity because the evidence shows that disparities in development and achievement emerge early in the life course (Heckman, 2011), and thus this is a critical phase at which to intervene (Conti et al., 2011). Furthermore, this would leverage an already existing effort, as the U.S. Department of Education has committed to promoting the use of data to advance equity in the fiscal year 2017 (ED, 2016). There are potential limitations with the availability of evidence on reducing disparities in learning outcomes beyond early childhood and elementary levels. Additionally, the state of evidence on racial and ethnic minorities for whom English is not the first language needs to be taken into consideration. Otherwise, efforts to promote equity could unintentionally be hindered.

Role of Law Enforcement and the Justice System

It is increasingly clear that an important focus for community interventions should be building trust between law enforcement and local communities. The final report of The President's Task Force on 21st Century Policing highlights trust as the cornerstone for just and efficient law enforcement and community safety (The President's Task Force on 21st Century Policing, 2015). Yet, concerns about police brutality, bias, and a lack of accountability severely undermine trust in law enforcement, especially among racial and ethnic minority communities. 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). In theory, proactive strategies that are implemented with a community policing approach address the proximal conditions that engender public safety issues such as crime, social disorder, and fear of crime (Bureau of Justice Statistics, 2016). Community policing can lead to greater permeability and interdependence between departments and communities (Gill et al., 2014). Building sufficient trust for effective community policing requires that police get to know residents, which can be achieved through police–resident social events, community gatherings, and public hearings.

The National Academies' Committee on Proactive Policing–Effects on Crime, Communities, and Civil Liberties in the United States¹² is conducting a study that reviews the evidence on the effects of various forms of proactive policing, including community policing. The review includes an assessment of proactive policing approaches and their effects on crime and disorder, discriminatory application, legality, and community receptiveness.

Specific strategies for community policing vary. One strategy to improve community oversight is the civilian review board, a mechanism by which community members can review police conduct (Finn, 2001). 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).

Another approach to community policing is to achieve racially and ethnically representative police departments. Research suggests that communities have greater levels of trust in law enforcement when police demographics mirror the community (DOJ, 2015, 2016). This is rarely the case, however, as the proportion of sworn officers who are white is typically much higher than the proportion for the communities they serve (DOJ, 2015, 2016).

The predominant theory for why some communities have more violence than others centers on the differing capacity of communities to come together to control crime (Sampson, 2012). Communities experience different organizing against crime: some are able to come together and use their resources to control unwanted criminal elements, while others are less effective. Typically, able communities have greater financial resources and are relatively stable (i.e., residents have lived in the community for a long time and thus tend to know each other and have a vested stake in the community). These structural conditions—resources and stability—create conditions under which residents are more likely to agree on what constitutes a crime problem and under which they can work together to control crime via informal and formal means. Formally, residents will call the police when crimes are witnessed and otherwise work to develop positive relations with the police. Informally, they rely on healthy social capital and networks to transfer information and social control. For example, in a neighborhood where a resident knows his or her neighbors and feels a sense of belonging and attachment, he or she is more likely to recognize unwanted behavior as suspicious (e.g., a group of teenagers lurking in an alleyway), notify other residents, or call the police. This is an example of collective efficacy: communities using their relationships, shared norms, trust, and social cohesion to come together to control crime.

Not all communities benefit from the same degree of collective efficacy (Sampson et al., 1997). In some communities, some neighbors may not know who is “suspicious,” and different neighbors may not perceive the same individuals as “suspicious.” Some neighbors may not alert other neighbors because they do not know or trust these neighbors. They may doubt that anything will be done about the issue and think it is a frequent occurrence. Witnesses may fear the police themselves and be reluctant to call. Such communities lack the collective efficacy to come together and address crime, and such places are often characterized by poverty and residential instability (where residents are not attached to neighborhoods).

One possible strategy to build and improve collective efficacy is to identify and obtain the resources necessary to improve the physical condition of neighborhoods. Various grant programs (such as the Seattle Department of Neighborhood's Neighborhood Matching Fund¹³ and other Hope grants¹⁴) provide resources to communities that propose their own solutions (Ramey and Shrider, 2014). These community-driven approaches have been shown to increase attachment to place, reduce violence, and improve mental health (see work, for example, by Charles Branas at the University of Pennsylvania Urban Health Lab) (Culyba et al., 2016; University of Pennsylvania, 2013). 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). Communities with stronger ties among these actors are more able to hold these actors accountable. Other potential strategies include creating community watch organizations and block groups, which can facilitate social cohesion; strengthening neighborhood institutions such as neighborhood associations, schools, churches, businesses, and community centers; and facilitating the ability of residents to own their homes, fostering a stronger attachment to their community. Community policing approaches are thus fundamentally multi-sectoral because they promote organizational strategies that facilitate collaborative relationships among various community stakeholders.

As noted earlier, the final report of The President's Task Force on 21st Century Policing highlights the importance of building and maintaining trust between law enforcement and local communities (The President's Task Force on 21st Century Policing, 2015). Recent events illustrate the crisis of trust and accountability that is taking place in many communities across the country. Concerns about police brutality, bias, and procedural injustice severely undermine the efficacy and legitimacy of law enforcement. This is especially acute among racial and ethnic minority communities. 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

Governance for “Health in All Policies” or Cross-Sector Collaboration

State policies in such areas as education, development, and land use have clear parallels to federal policy and can significantly shape how communities respond to health disparities. There are several state-level examples of cross-sector collaboration intended to improve health and health equity. In 2010 the State of California created a Health in All Policies Task Force—representing 19 state agencies, departments, and offices—under the auspices of the state's Strategic Growth Council, aiming to build interagency partnerships across state government and to address issues of health, equity, and environmental sustainability. This is the first formal state-level body of its kind. Its goals describe a broad definition of health which includes air and water quality, natural resources and agricultural lands, the availability of affordable housing, infrastructure systems, public health, sustainable communities, and climate change. Such HIAP approaches and governance structures have also been adopted at the community level.

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.). The Nashville Metropolitan Planning Organization, for example, increased the percentage of projects that incorporate safe walking and biking elements from 2 percent in 2005 to 70 percent in its 2010 plan (Nashville Area Metropolitan Planning Organization, 2010). Although the plan does not use the term “health equity,” its monitoring of performance and impacts is framed by Title VI of the Civil Rights Act of 1964 and by the 1994 Executive Order on Environmental Justice, and the overall planning process is informed by transportation equity principles. Specifically, the project evaluation factors described in the plan include questions on health and environment, such as: “Does the project aid/harm the advancement of social justice and equity opportunity to destinations throughout the region?” and “How can the project be scoped to mitigate any negative impacts to predominantly low-income or minority communities or persons with a disability?” (Nashville Area Metropolitan Planning Organization, 2010).

National Initiatives

Several national initiatives have served to further cross-sector partnerships to improve health, livability, and economic development. In 2015, NACCHO funded three HIAP demonstration sites (Houston, Baltimore city, and San Diego) with funding from the National Center for Environmental Health and the Agency for Toxic Substances and Disease Registry, both of the U.S. Centers for Disease Control and Prevention (CDC). In September 2014, the CDC provided support for the 3-year Plan4Health initiative, jointly led by the American Public Health Association (APHA) and the American Planning Association (APA) and implemented through 18 local coalitions, which include APHA and APA local affiliates. Plan4Health coalitions “incorporate equity into many aspects of their work to increase opportunities for active living and access to health foods” (Norcross, 2016). However, “getting to the root issues of why inequities exist can be complex, time consuming, and takes the buy-in and contributions of traditional and non-traditional cross-sector partners” (Makara, 2016). Plan4Health has assembled a collection of resources to support coalitions in this vital work, including A Refresher on Health Equity and the Transportation and Health Tool developed by the DOT and the CDC (Hartig, 2015; Makara, 2016). In 2016 the Association of Collegiate Schools of Architecture and the Association of Schools and Programs of Public Health (ASPPH) held their first-ever joint conference, titled Building for Health and Well-being: Structures, Cities, Systems. One conference track focused on what it called Acupunctural Urbanism: Advocacy, Equity, and Community Based Initiatives. In 2014 the American Institute of Architects held a summit on health and design, keynoted by the acting U.S. Surgeon General, and launched the Design and Health Research Consortium in 2015 (of which ASPPH has become a member). The consortium's inaugural proceedings included a session on resilience and equity which concluded that ethnic and racial minorities are disproportionately exposed to harmful environmental factors and that “resilience in the context of health and environment must engage questions of race, ethnicity, income, and institutionalized prejudice” (AIA and ACSAAF, 2015). Such efforts—interprofessional, interdisciplinary, and cross-sectoral—enhance opportunities for fruitful collaboration to promote health equity in the practice of public health, architecture, and planning.

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).

Federal Government Initiatives on Health Equity

Over the past decade, there has been significant federal effort to coordinate actions aimed at advancing health equity. Below, the committee describes the considerable infrastructure for health equity that has been constructed within the federal government. 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) has been a key driver. Its stakeholders are the Federal Interagency Health Equity Team (FIHET), the offices of minority health at the U.S. Department of Health and Human Services (HHS), regional health equity councils, and health equity champions. Federal leadership for NPA is provided by FIHET, whose mission is to convene federal leaders to end health inequities by building capacity for equitable policies and programs, cultivating strategic partnerships, and sharing relevant models for action (FIHET, 2016). The partnership includes leaders from the Consumer Product Safety Commission and the departments of agriculture, commerce, defense, education, housing and urban development, justice, labor, transportation, veterans affairs, and health and human services. The ACA mandated the establishment of offices of minority health within six agencies of HHS: the Agency for Healthcare Research and Quality, the CDC, the Centers for Medicare & Medicaid Services (CMS), Health Resources and Services Administration, Substance Abuse and Mental Health Services Administration, and the U.S. Food and Drug Administration. The 10 regional health equity councils are independent, nongovernmental organizations comprising leaders and stakeholders from both nonfederal public (e.g., state government) and private sectors (e.g., academia, community-based organizations, health systems, health insurers) from within that region. The health equity champions program further extends the NPA's reach through pledges of support from organizations, advocacy groups, foundations, academic institutions, technical or subject matter experts, and community members.

The NPA has produced two major products to date. The National Stakeholder Strategy (NSS) for Achieving Health Equity laid out five goals and associated strategies in the areas of awareness, leadership, health system and life experience, cultural and linguistic competency, and data, research, and evaluation (NPA, 2016b). Within the NSS, the priorities for action and associated progress are to

• Educate and facilitate outreach on the Patient Protection and Affordable Care Act of 2010 (ACA): The Office of Minority Health is supporting implementation of the ACA by helping connect minority consumers and communities of color with information about affordable health insurance options and partnering with CMS and other federal agencies and private-sector organizations to support to outreach efforts.
• Support the implementation of the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care: The Think Cultural Health website (HHS, n.d.) 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).
• Strengthen the nation's network of community health workers, who play a key role in disease prevention and health promotion: NPA activities primarily focus on supporting the integration of community health workers into clinical and preventive care workforces through the regional health equity councils (RHECs) (NPA, n.d.).
• Promote the integration of health equity into policies and programs: Activities include a “health equity mapping” pilot to work collaboratively with volunteer FIHET organizations to map the relationship between their priorities and core functions and the attainment of health equity; FIHET has partnered with the Democracy Collaborative to convene federal and nonfederal leaders from health, community economic development, and other sectors to identify key conditions needed to drive strategic cross-sector collaboration to promote health equity; RHECs have published regional blueprints and health equity report cards; and NPA has collaborated with nongovernmental partners who are key conveners of decision makers at the local and state levels (e.g., the National Indian Health Board and the Association of State and Territorial Health Officials) (NPA, 2016c).

The complementary HHS Action Plan to Reduce Racial and Ethnic Health Disparities includes an HHS commitment to an ongoing assessment of the effectiveness of policies and programs related to reducing racial and ethnic health inequities and accountability for increasing health insurance coverage, improving quality, building data capacity, preventing disease, and strengthening cultural competency to create a nation free of inequities in health and health care (HHS, 2011). Box 7-6 summarizes an Office of Minority Health report on the federal government's role in health equity.

BOX 7-6

Office of Minority Health Report on Health Equity in the Federal Government.

Finally, CMS is implementing several activities that will provide opportunities for partnering across sectors in the community. Its quality strategy details agency priorities for health care quality improvement and identifies the elimination of disparities as a foundational principle along with enabling local innovations, strengthening infrastructure and data systems, and fostering learning organizations (CMS, 2016). The CMS Equity Plan for Medicare will affect change through several unique CMS levers (CMS, 2015). These include quality improvement networks and quality improvement organizations, CMS programs, policy, data, access to stakeholders, and communication tools. The plan focuses on Medicare populations that experience disproportionately high burdens of disease, worse quality of care, and barriers to accessing care.

Guided by a framework that includes three interconnected domains—better understanding and awareness of inequities, identifying and creating solutions based on that understanding, and accelerating the implementation of measurable actions to achieve health equity—the CMS Equity Plan for Medicare has six priority areas. Three focus on meeting the needs of diverse populations through enhanced language access, physical access, and community health worker training. The other three center on data collection, reporting, and analysis; evaluating impact and integrating solutions across CMS programs; and the development and dissemination of promising approaches to reduce health disparities.

The current state of health disparities is both deeply troubling and a call to action to stem the high human and economic cost of health inequity. Clearly, considerable support for addressing health equity has been established in HHS and across the executive branch through the Federal Interagency Health Equity Taskforce. Sustaining and elevating this cross-government 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).

The council builds on the foundation of earlier efforts, including a 2010 executive order, and it seems to signal attention at the highest level of government to the notion of helping all communities to successfully confront their challenges “including crime, access to care, opportunities to pursue quality education, lack of housing options, unemployment, and deteriorating infrastructure” (The White House, 2016).

Recommendation 7-7: The committee recommends that key federal government efforts, such as the Community Solutions Council, that are intended to support communities in addressing major challenges, consider integrating health equity as a focus.

A health equity focus could mean undertaking such efforts as

• Determining how government decisions in health and non-health sectors could affect low-income and minority populations, including unintended negative consequences.
• Convening key stakeholders to explore financing structures through which companies, philanthropy, and government can together fund key health equity initiatives, including efforts to generate better, timelier, and more locally relevant data.

The importance of considering the unintended consequences of government policies is evident. For example, Chapter 3 outlines several examples of historical government policies that shaped government investment, land use, transportation planning, and other features of communities with disproportionately negative effects on access to housing, safety, social cohesion, family stability, and health outcomes in low-income and minority populations (Freeman and Braconi, 2002; IOM, 2003; Levy et al., 2006; Prevention Institute, 2011; Vélez, 2001; Zuk et al., 2015). Weighing the consequences on health outcomes, however, will require access to more varied and meaningful sources of data and may demand resources for analysis and assessment. The unique circumstances and context of each community (e.g., defined by census tract or zip code) may make it difficult to undertake such an assessment of potential consequences in a way that considers their full scope.

Public–private partnerships offer opportunities for innovation and alignment of resources that can achieve greater efficiency and effectiveness. Examples include pay-for-success financing models to support early childhood development and other programs, the Sustainable Communities federal partnership that brought together public- and private-sector actors to align their efforts, and clean energy financing arrangements (IOM, 2015a; PolicyLink, n.d.; Probst, 2014).

The language of the Executive Order (excerpted in Box 7-7) demonstrates recognition of the importance of equity (not explicitly health equity) and the determinants of health and well-being: for example, “Place is a strong determinant of opportunity and well-being. Research shows that the neighborhood in which a child grows up impacts his or her odds of going to college, enjoying good health, and obtaining a lifetime of economic opportunities” (The White House, 2016). 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). The new executive order also references the Community Solutions Task Force, created in 2015 and which the new Council is intended to replace. Since 2015, the Community Solutions Task Force, comprising executive departments, offices, and agencies across the federal government, has served as the primary interagency coordinator of agency work to engage with communities to deliver improved outcomes. This order builds on recent work to facilitate interagency and community-level collaboration to meet the unique needs of communities in a way that reflects these communities' local assets, economies, geography, size, history, strengths, talent networks, and visions for the future. The distinguishing feature of the new council is that it is to be located in the White House and be cochaired by an Assistant to the President or the Director of the Office of Management and Budget, as designated by the President and by one of several cabinet secretaries identified in the order (e.g., DOJ, HHS, HUD).

BOX 7-7

Excerpt from Executive Order Establishing a Community Solutions Council.

The Executive Order also calls on the council to conduct outreach to “representatives of nonprofit organizations, civil rights organizations, businesses, labor and professional organizations, start-up and entrepreneurial communities, State, local, and tribal government agencies, school districts, youth, elected officials, seniors, faith and other community-based organizations, philanthropies, technologists, other institutions of local importance, and other interested or affected persons with relevant expertise in the expansion and improvement of efforts to build local capacity, ensure equity, and address economic, social, environmental, and other issues in communities or regions” (The White House, 2016).

The committee hopes that the council could build on the foundations of health equity work presented in this report and elsewhere and take action toward solutions, including cross-sector, community-driven, and public–private partnerships. It needs to be more than merely a symbol to avoid a disempowering effect on communities. Furthermore, there is a large power differential between a group of such high profile actors and communities and community members. The committee hopes that council engagement of community members will be conducted in the spirit of respect and authentic partnership. As outlined in this report, communities are where change takes place, and the members of communities are best equipped to know what is needed to effect change in their community.