14 Inside and Outside Strategies to Advance Health Equity within Local Public Health Practice

| By Jonathan Heller & Lili Farhang |

Public health leaders from across the country – including organizations like NACCHO and BARHII and individuals like Dr. Tony Iton and Jeanne Ayers – have written extensively about what health equity practice looks like. Thankfully, their insights have a lot in common and are mutually supportive. As HIP provides health equity trainings and works with emerging leaders through our Public Health and Equity Cohort, we’ve also developed our own ideas about how to advance health equity within local public health.

As organizations and agencies seek to make health equity a guiding force of their work, we wanted to share a summary of these key elements of health equity practice based on what we’ve seen represented across many resources and based on our own experience. (This is just a brief list of those key elements. See here for a more detailed write-up of these.)

We use the term ‘practice’ to highlight that there is not a recipe or a toolkit that will provide a health department with step-by-step instructions as they build their capacity to advance health equity. Instead, doing so takes a combination of both hard and soft skills that must be molded to the local context, practiced and refined, and adapted as the context shifts. There is no quick fix that will get a health department where they need to be; advancing health equity requires ongoing work and dedication.

14 Elements to Advance Health Equity Practice:

Inside strategies: Internally focused practices to advance health equity
1. Focus on addressing the “causes of the causes of health inequities” – oppression and power
2. Prioritize improving the social determinants of health through policy change
3. Build understanding of and capacity to address equity across the organization
4. Support leadership, innovation, and strategic risk-taking to advance equity
5. Change the narrative of what leads to health
6. Commit the organization and its resources to advance equity
7. Use data, research, and evaluation to make the case
8. Change internal practices such as hiring and contracting

Outside strategies: Externally focused practices to advance health equity
1. Build partnerships with communities experiencing health inequities in ways that intentionally share power and decision making and allow for meaningful participation
2. Build alliances and networks with community partners to protect against risk and build power
3. Build alliances with other public agencies
4. Engage strategically in social justice campaigns and movements
5. Change the administrative and regulatory scope of public health practice
6. Join broader public health movements to advance equity

We’ve written about our theory of change, the need to address power and racism, and the inside-outside strategies that are needed to advance equity at a health department in other blogs. Our goal here is to further enumerate a set of practices – focused internally and externally – that health departments can implement (over time!!) to advance health equity. Importantly, doing just one or two of these will not achieve the outcomes to which we all aspire. And the inside and outside strategies are not independent; they must be used together, strategically, through intentional and adaptive processes to achieve our goals.

We will continue to refine these elements, provide examples of how they are being implemented, discuss barriers to implementation and potential solutions, and develop a set of self-reflective questions health departments can use to evaluate their current practice and identify next steps.

The following resources were used to help generate these elements of health equity practice:
• Association of State and Territorial Health Officials. Role of the State and Territorial Health Official in Promoting Health Equity. 2013.
• Bay Area Regional Health Inequities Initiative. Local Health Department Organizational Self-Assessment for Addressing Health Inequities: Toolkit and Guide to Implementation. 2010.
• Ehlinger, Ed. We need a Triple Aim for Health Equity. Minnesota Medicine. 2015.
• The California Endowment. Advancing Health Equity Awards: Reviewer’s Packet. 2014.
• Health Resources and Services Administration and the Region V Collaborative Improvement and Innovation Network on Infant Mortality. Foundational Practices for Health Equity: State Self-assessment. Forthcoming.
• Human Impact Partners. Public Health and Equity Cohort Curriculum. 2016.
• Iton, Anthony. Health Equity: Moving from the Margins to the Center. NACCHO Exchange. 2016.
• National Association of County & City Health Officials. Expanding the Boundaries: Health Equity and Public Health Practice. 2014.
• National Association of County & City Health Officials and the Ingham County Health Department. Tackling Health Inequities Through Public Health Practice: A Handbook for Action. 2006.