When public health departments support all aspects of the public’s well-being – beginning with striking at the roots of health inequity – it can create transformational change. Part of this process is encouraging people in communities to determine their own futures – to express agency – something that is rooted in action and power. So, how does local public health get there?
We already have examples of success. For instance, local public health departments have been at the forefront of health equity work by building internal capacity and infrastructure, fostering strategic community partnerships to build power and engage in social justice work, and working across government agencies to develop shared ownership for health equity.
However, although these examples exist, all too often public health’s efforts fail to improve population health – and often because of the fear of failure.
There is fear of trying new initiatives that might not work out. There is fear of running out of time, will, allies, and money. There is fear of not meeting funders’ expectations, even when their expectations do not align with the community’s needs. There is fear of going against the governing bodies, such as mayors and other officials, even when their agendas may conflict with the community’s needs. And, underlying all of this, is the fear of losing ever-dwindling vital resources.
Addressing the roots of health inequity requires operating out of a social justice – and not just a medical – framework. In their role as scientists, public health practitioners can no longer shy away from addressing issues of unequal power and structural bias, such as racism.
While Bridging Health and Community’s (BH&C) 12 Principles are not new to public health practitioners, how they are framed within the context of building community agency is powerful. They describe an inclusive, participatory, and responsive processes to create a holistic shift in how healthy communities might be developed. Too often, we in local public health inadvertently perpetuate the problems we are looking to address – especially when we exclude the community’s voice in our efforts. It renders our work fragmented and narrowly focused on specific health conditions, rather than being a holistic approach that appreciates and responds to how good or bad health is the result of the many systems that serve a community, and the intersections between them.
As a framework for overcoming this narrowness, the 12 Principles resonate strongly with how NACCHO and local public health departments should – and often do – engage the communities we serve. For example, the 12 Principles directly correspond with our Mobilizing for Action through Planning and Partnerships (MAPP) approach for guiding health departments and their cross-sectoral partners to work collaboratively to improve community health through health assessment and planning.
What does addressing the roots of health inequity look like in practice? At BH&C’s May 2017 symposium, Community Agency & Health, the session Designing and Testing New Business Models, facilitated by Jodie Lesh of Kaiser Permanente described one such effort. I was inspired by her presentation describing how staff realized Kaiser was underserving key South Los Angeles communities. Despite having more members than wealthier communities, South Los Angeles did not have the equivalent number of doctors and facilities. Kaiser found it was unintentionally reinforcing the structures and beliefs that often prevent services and economic opportunities from being located in communities, particularly communities of color, which have been historically disadvantaged. This prompted Kaiser to go against the forces that traditionally drive their work, and to do things differently to correct the problem.
Echoing the 12 Principles, one of NACCHO’s partners, Human Impact Partners, has developed a full range of strategic practices rooted in the theory that to systematically dismantle the patterns of othering and exclusion in government practice, we must pursue wall-to-wall transformation of how local health departments work, internally, with communities, and alongside other government agencies. This inside/outside approach requires health departments to build internal capacity and a will to act on the social determinants of health and health equity.
These practices clearly align with the 12 Principles and are articulated in HIP’s HealthEquityGuide.org website, a remarkable resource with inspiring examples of how health departments have advanced health equity, both internally (within their departments) and externally (with communities and other government agencies). Of particular note are more than 25 detailed case studies from departments that describe how they advanced their practice, as well as more than 150 resources from allied organizations and others to advance the strategic practices. The Health Equity Guide clearly documents how the 12 Principles are made real in communities.
A local health official once commented that the role of local public health is to be the mirror and conscience of the communities they serve, bringing the health and health disparities data to the community to raise awareness of what needs to be addressed and the consequences of inaction.
For local public health to truly support community agency, this consciousness raising needs to be done in coalition with the communities they serve, respecting not just professional knowledge, but also community knowledge. By acknowledging that communities have agency, rather than conceiving of residents as victims who need our help, we can contribute to some of the key elements that cultivate community agency: transparency, full participation and accountability for decision-making.