To achieve health equity, public health needs communities—and communities need power

By Bechara Choucair, Kaiser Permanente; Judy Monroe, CDC Foundation; and Lili Farhang, Human Impact Partners

The U.S. public health system, long neglected and recently battered by the demands of a pandemic, is about to face another daunting challenge. Experts have consistently warned that state and local public health departments would face a funding cliff when special COVID-19 funding ended—and that moment has arrived.

Public health teams are losing funding at the very moment their knowledge, expertise and commitment to service are most needed. We’re reminded almost daily of health threats from infectious disease , our changing climate and more. When protecting the public’s health means doing more with less, we can’t expect health departments to go it alone. They need support, resources and partnership from health care, the private sector, and non-traditional partners.

Health departments, too, will need to find new ways to thrive. Perhaps the biggest opportunity is to partner more deeply, equitably and strategically with the communities they serve. Community-based organizations (CBOs) represent a powerful yet under-appreciated pillar of the health system in the United States. With unmatched expertise and the trust of their communities, CBOs have been shown to greatly extend the impact of both health departments and health care delivery systems.

Our own organizations recently worked together to understand how health departments and CBOs could better partner to advance health equity. What we found was for CBOs to contribute fully to public health, they need greater power and influence, and it will take a shift in mindsets from health departments to fully engage CBOs as true partners in the creation and delivery of services for their communities.

CRITICAL PARTNERS, TOO OFTEN AT ARMS’ LENGTH

 CBOs already work at the local level to support their communities’ health and wellbeing. They’re natural and powerful allies in advancing public health. A century ago, in fact, community-based social welfare organizations helped drive the creation of the public health field itself, tackling critical issues like water quality, sanitation and zoning that dramatically improved living conditions and extended life expectancy.

More recently, the power of CBOs was apparent during the COVID-19 pandemic when they helped extend the capacity of public health organizations throughout the crisis. They supported health departments in their contact tracing efforts, used their trusted voices to fight health misinformation, and employed their intimate local knowledge to help vaccines reach people who needed them most.

Recognizing the value of these relationships, we wanted to understand what it would take to continue elevating the impact of these partnerships, even beyond the pandemic. Our organizations consulted with more than 140 leaders and staff from health departments, CBOs, and allied organizations across the country. Through interviews, focus groups, and insight sessions, we focused on identifying institutional levers that can strengthen partnerships between health departments and CBOs, from leadership and governance to data measurement and funding approaches. These efforts culminated in a new report, which offers a roadmap for understanding how health departments can be true partners with the communities they serve—and more effectively collaborate with CBOs to make that happen.

These conversations highlighted an important truth: for truly effective partnerships that advance health and health equity, communities and individuals most impacted by systemic injustices must be in the driver’s seat. CBOs emphasized “understanding, acknowledging, shifting and sharing power” as the key starting place for health departments wishing to build partnerships with communities. These characteristics about power shifts were emphasized in particular in conversations with CBOs that represented and served historically marginalized communities that have experienced the worst health inequities.

What does shifting and sharing power look like in practice? It’s collaborative decision-making with CBOs on how public health funding is spent in the communities. It’s making sure CBOs have access to health data to make informed decisions on how it’s used. It’s shared leadership in planning and implementing public health initiatives. It’s participatory budgeting and co-developed funding proposals. Any number of these changes could help ensure CBOs and communities most impacted by inequities are centered in public health work.

One CBO leader explained that health departments should “try and have the empathy to understand [community] challenges” and that there may be more they have to do “to truly be equitable.” Health department personnel also affirmed the value of CBO perspectives in shaping public health work, with one interviewee saying, “Communities know exactly what they need to do…I also wish that we [health departments] understood communities don’t need us—we need them.”

SHIFTING POWER TO AND WITH COMMUNITY-BASED ORGANIZATIONS COULD TRANSFORM PUBLIC HEALTH

Getting out of old patterns always takes hard work and rigorous self-examination. But the payoff is well worth it. Shifting to and sharing power with CBOs can truly transform public health, allowing health institutions to tap into community knowledge, expand their capacity, and build trust.

For health departments, this would ensure they’re spending their limited money and resources on the most effective programs. It could also expand their capacity to collect, analyze, and share community health data, and ensure trusted community voices are dispelling health misinformation. For other stakeholders—like hospitals and health care systems—this could ensure their patients are quickly connected with CBOs that can address the social needs that impact health, like access to housing and nutritious food. These shifts could be game changing and allow our health institutions to make meaningful strides in advancing health outcomes and achieving health equity.

Health care delivery systems can also play a more meaningful role in supporting these shifts by making a shift of their own—aligning their priorities to focus on the health needs identified by their community and public health partners. When each part of our health system is motivated to get and keep people and communities healthy, public health, healthcare delivery, and CBOs can form and expand mutually reinforcing partnerships that will save and improve lives.

Perhaps one of the most crucial components of this approach is the opportunity to create—and in many cases, repair—community trust. Historical exclusion, neglect, disempowerment, and mistreatment have created community distrust in our health ecosystem, with unique challenges for governmental public health, which is often viewed as responsible for many unjust policies. CBOs, which are directly woven into the fibers of their neighborhoods, are key to healing these past harms. If health institutions want to achieve equity, we must confront systemic inequities head on. Transforming partnerships with CBOs—namely by shifting and sharing power with them—is a critical component of this work.

As we look to the public health challenges on the horizon, the health system needs to do things differently. Not only do we need to get out of our silos, but we also need to partner with the communities we’re serving. CBOs are foundational to the success of any health institution’s efforts to advance health because they are experts in what their communities need to truly be healthy.

We must integrate CBOs as critical decision-makers in the health infrastructure of our communities. These partnerships must be authentic, equitable, and enduring. Having CBOs meaningfully lead public health work can ensure communities have the power to determine their own future—and get us closer to a healthier, more equitable future for every community.