Changing the Dynamic

Emily Yu and Pritpal S Tamber

October 23, 2019

It feels like every week there’s a headline claiming that [insert hospital name] invested in [choose between housing, transport or food] and saw some amazing return on investment. Often, these investments involve some kind of multi-sector collaboration but rarely is there much information on the realities of collaborating.

This week’s interviewee, Emily Yu, has deep and wide access to multiple multi-sector collaboratives. As Executive Director of The BUILD Health Challenge, she’s watched 37 collaborations mature, including grappling with the realities of collaborating. I caught up with Emily as BUILD began preparing for its next cohort. 

Pritpal S Tamber: Hi Emily. Let’s start with what BUILD stands for, and why.  

Emily Yu: Thanks, Pritpal, for opening up this conversation. The BUILD Health Challenge (BUILD) is a national awards program funded by 11 foundations that supports cross-sector collaborations tackling the root causes of chronic disease in a community. BUILD stands for Bold, Upstream, Integrated, Local, and Data-Driven. Each participating community designs their own strategy around this framework to improve not only health outcomes, but also to advance health equity and create sustainable solutions. 

Pritpal: OK. So, how did you go about choosing the communities that make up the 37? 

Emily: Communities across the country are invited to respond to an open call for applications. We look for established partnerships that have a history of working together, strong resident engagement, and a laser-like focus on health equity. From those partnerships we look for innovative approaches that might contain ‘quick hits’ that foreshadow sustainability. BUILD is ultimately looking for communities ready to make systems-level change in the policies and procedures that affect local health outcomes. 

Pritpal: What do you mean by “quick hits”? 

BUILD awardees fostering collaborations to advance sustainable improvements in community health

Emily: Quick hits are what we describe as programmatic milestones that are necessary for big, sustainable, systems-level changes. These ‘quick hits’ – or milestones – indicate to us that norms are ready to be changed. Examples of this range from the strength of partnerships to greater community ownership of an issue to changes in organizational policies and structures. We’ve found that helping communities enhance or scale these milestones can help them change systems more quickly and effectively. 

Pritpal: What do you mean by ‘partnership’? 

Emily: The partnerships that participate in BUILD are required to include a community-based organization (CBO), a hospital/health system, and a local public health department. In our view, having these three stakeholders at the table is critical to facilitating the long-term change that is necessary for better health. Also, the BUILD creators purposefully required that the lead partner be the CBO, the idea being to make community engagement a core part of the work. The CBO is also the recipient of the monetary award – up to $250,000. 

Pritpal: Why is it important that the CBO gets the money? 

Emily: Great question! When the creators of BUILD put their heads together, they saw this as an opportunity to level the playing field in community health. Often times, the hospital/health system or local public health department get the money, despite the fact that they’re already better resourced and staffed. Assigning the lead role to the CBO and awarding them the money helped to level the playing field with the other partners. I’ll add that the participating hospital/health system is also required to ‘match’ the funding, which must also go to the CBO. 

Pritpal: Have you seen any ‘levelling’ in the playing field? 

Emily: Yes! Various members from different participating collaboratives have told us that the arrangement has changed the dynamic between the partners in a positive way and led to the formation of deeper community ties that likely would not have happened otherwise.

Pritpal: Oh, excellent. OK, but how does the approach make collaboration more productive? 

Emily: Most people agree that cross-sector collaboration is necessary to address complex and large-scale issues such as community health. Yet, the work of collaboration is all too often left under-resourced. We’ve heard from participants that prior to being part of BUILD they struggled to make ‘collaboration’ happen, despite their best intentions. So, our aim with supporting these partnerships is to allow for collaboration to flourish through the use of money – and the time and space it affords. 

Pritpal: You know, sometimes these ideas of time and space can be quite abstract. What does it look like in practice? 

Emily: It depends on the challenges of each partnership but I’ll give you an example. Several BUILD communities wanted to use data to pinpoint the places where people with severe asthma were clustered. To do so, the partners had to share data with one another. The desire to share data was easy but the real hurdle came when trying to formalize that data sharing into an agreement. This was partly due to HIPAA regulations but also partly due to the needs and concerns of each of the partners’ legal teams. It took much longer than anyone expected.

Pritpal: I hear that a lot. 

Emily: Right. In situations like this, the support and resources from BUILD specifically focused on advancing collaboration proved to be vital to the team’s ability to secure an agreement among partners. BUILD tends to bring to the forefront the need and urgency to collaborate for all partners, it’s like an action-forcing event in many ways because of how it’s structured.

Pritpal: OK, that’s a good, concrete example. Thank you. Tell me more about the L of BUILD. 

Emily: The L stands for local and refers to engaging residents and community leaders as key voices. How that’s done differs per community, but we’ve seen that the ones doing it well tend to have established processes for it, including reaching into traditionally disenfranchised groups. We’ve seen that collaboratives working with residents lead to longer lasting impacts on community health. 

Pritpal: What does that mean for more traditional stakeholders in health? 

Emily: For them, it can be a trade-off. They have to learn how to ensure that power is distributed. And they might have to get used to the decision-making process taking longer than they’re used to now that more voices are at the table. In more technical terms, we’ve mapped out the evolution of ‘local’ for many of the communities that have participated in BUILD. 

Pritpal: What does that mean? 

Emily: Those just getting started with resident engagement tend to rely on representation by a community-based organization – not necessarily the residents themselves. At the next level of evolution there may be engagement periodically with community leaders or residents, although not regularly or at scale. For those that are more advanced, you’ll see some form of regularity and scale, as well as the existence of a process to engage a large number of residents, including disenfranchised groups.

Pritpal: Oh, interesting. So, have you also seen a continuum in the B, U I and D of BUILD? 

Emily: Yes, and we’ve also learned from our communities that one of their frustrations has been being able to measure or gauge one’s progress in advancing health equity. It’s not helpful to rely solely on health outcomes for measurement. It’s also important to be able to gauge whether you’re working in a new way, and how deeply. By observing past BUILD communities, we’ve been able to identify specific milestones per letter – B, U, I L and D – and mapped them out as a ‘progress continua’. The per-letter continua can be applied to just about any community looking to drive sustainable improvements in health. It’s important to note, however, that it’s designed to measure a community only against themselves, not in comparison to others. You can read about it in much greater detail in the “Getting BUILD Ready Guide.” 

Pritpal: Fascinating. So, are you getting a sense of which of the letters, or what levels of emphasis on each letter, is key to success? 

Emily: That’s what everyone wants to know! Perhaps not surprisingly, it really requires a mix of all five to work best. If a site excels in one or two areas, that’s great, and can often lead to one of the precursors for systems change in a community. But to really see systems-level changes that are sustainable, that takes all five parts of BUILD.

Pritpal: Ah, OK. But surely, after all you’ve seen, you’re itching to tell new collaboratives what you’ve seen work elsewhere? 

Emily: We are and we do! We want to replicate and scale the BUILD model. But we have to be careful. BUILD is a dynamic framework that can be applied at various stages of a community’s journey towards sustainable improvements in health. It’s not ‘the perfect solution’. It’s a flexible approach that can be tailored to fit just about any community. So, although we want to share what we’ve seen amongst the current 37, we have to be careful not to present any of it as ‘the solution’. 

Pritpal: So, how are you intending to handle that tension in your next cohort? 

Emily: We’re clear that our knowledge, framework, funding and support really just sets the table. What matters is whether there is true cross-sector collaboration and whether solutions are genuinely community-driven. If so, it becomes possible for community efforts to flourish, leading to ground-breaking innovation and fail-forward learnings. 

Pritpal: Got it. So, how do you think this work sustains when the BUILD money runs out? 

Emily: The sustainability conversation comes into play on day one with awardees. We help them identify and execute new streams of funding. It’s hard but we’ve seen partnerships develop incredibly sophisticated streams of funding. But it’s not just about money. BUILD also works with communities to focus on the long-term, such as policy change at the local level, new reimbursement mechanisms, structural changes within organization, and other system-level changes that have the potential to last. 

Pritpal: Fascinating. So, what’s next for the BUILD Health Challenge?

Emily: It’s an exciting time for BUILD! We’re launching the third cohort in mid-November. I can’t share which communities were selected, but I can tell you there are 18 from across the US that will be putting the BUILD principles into practice. Together, they will form the newest group of BUILD awardees that are going to share their successes and failures on their journey to advancing community health. Next year is also our five-year anniversary, so we’re going to use that milestone to reflect, look across all three cohorts, and share some new insights with communities that are aligned in their effort to move resources, action, and attention upstream.

Pritpal: That is, indeed, exciting. Well, I wish you well and hope you’ll come back and tell us more about your work in the future. 

Emily: Thanks so much, Pritpal, for hosting this conversation! I’ll add that we’ve been capturing stories, outcomes, and learnings from our second cohort so stay tuned this Fall for new takeaways that may be of use to your readers. Visit buildhealthchallenge.org.

What strikes me about BUILD Health is how much they’ve learnt about the realities of cross-sector partnering. Eye-catching headlines about amazing returns on investment often obfuscate the nitty gritty of what’s needed to make collaboration more likely and more successful. That said, while I’m pleased they’ve documented their learning, fashioned a framework and built some tools, it seems to me that such an important initiative could – and perhaps should – get into taking their knowledge on the road and helping others to bring about change. I hope they take up the mantle.  

Emily Yu

Executive Director at The BUILD Health Challenge

Emily is committed to driving sustainable improvements in health and is leading the charge to cultivate community collaborations that are working to give everyone a fair chance to be healthy. With nearly two decades of experience in program development and social marketing strategy implementation, for both the public and private sectors, Emily brings together a unique perspective that fuels her passion for both identifying and proving sustainable models for social change.

Pritpal S Tamber

Independent Writer, Researcher & Consultant | pritpal@pstamber.com

I'm an independent writer, researcher and consultant focussing on community health and medical information. I'm a former physician, medical editor and medical publisher, and also the former Physician Editor of TEDMED. I began my career at The BMJ. For more information, see the About page.

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