How Aligning Sectors Builds Resilient, Equitable Communities

Abstract

Communities of color have been particularly affected by the COVID-19 pandemic, revealing weaknesses and structural inequities in systems of care and support. Disparities in how the virus affected different people and communities are evident in nearly every aspect of the pandemic including risk of exposure, infection, hospitalization, and death, as well as in the vaccine rollout. We know this inequity is caused by conditions much broader than a single viral molecule. Neighborhood and physical environment, lifelong chronic and cumulative exposure to social and economic stressors,1 occupation and job conditions, income and wealth, and education all play a major role in the health and well-being of individuals and communities. Recovering from the virus and building resilience for future crises require a cohesive strategy to address these broader determinants of health for the long term. While people in health care, public health, and social services sectors in some communities have coordinated efforts for years, the pandemic has inspired others that have not worked this way before to begin aligning in ways that can address both short- and long-term goals and needs of individuals and entire communities. Early Insights Into the COVID-19 Response in Communities The Sentinel Communities Project, funded by the Robert Wood Johnson Foundation, the nation's largest philanthropy dedicated solely to health, examines the pandemic responses of 9 communities. Early findings show that when different sectors were more aligned prior to the pandemic—characterized by cross-sector collaborations that include hospitals and health providers, as well as businesses, schools and universities, and human services agencies—communities were better positioned to organize stronger, more equitable responses to the public health emergency.2,3 Take Milwaukee, Wisconsin, one of the nation's most geographically segregated cities and the first in the United States to declare racism a public health crisis. Community leaders developed a comprehensive plan to transform services and systems to address this. When the pandemic began, existing multisector efforts expanded to respond to local outbreaks of the virus and upstream effects that exacerbated them such as housing insecurity, mental health, and access to voting. A partnership of foundations and community organizations led by the Greater Milwaukee Foundation worked to address these issues in collaboration with community representatives and leaders and quickly activated funds to expedite the response and recovery. An Innovative Approach For the past 3 years, Aligning Systems for Health, a national initiative led by the Georgia Health Policy Center and supported by the Robert Wood Johnson Foundation, has supported 21 research grants4 and led a field of doers, supporters, funders, and researchers in understanding what makes efforts to align sectors like Milwaukee's successful and able to improve health equity and how other communities might approach this work. Because each community is unique in its specific strengths and challenges, what works for one community may not work for another. However, there are commonalities that drive successful efforts, whether responding to the COVID-19 pandemic or addressing broadband access, maternal health, the opioid epidemic, or other community priorities. A Framework for Aligning Sectors (Figure) offers an innovative approach to successfully align health care, public health, social services, and other sectors to jointly tackle complex challenges that matter to community members. The framework emphasizes 4 critical components5 sectors can implement: Shared purpose: The organizations involved establish shared areas of focus and outcomes in partnership with people who experience the worst effects of inequitable systems. Shared data: The organizations involved share data that are meaningful to all partners and that enable sectors to effectively coordinate activities and measure shared progress.6 Shared financing: The organizations involved create or access long-term financing supports, including appropriate incentives and shared accountability structures, that coordinate and partner with community members. Shared governance: The organizations involved maintain robust governance and leadership structures that include and elevate local representation and voices. FIGURE: A Framework for Aligning SectorsAs sectors address these core components, research and practice have demonstrated that 4 additional factors are necessary throughout successful aligning of systems. The centrality of these factors is the major differentiating point from the project's original theory of change.7 They are as follows: Community voices: The organizations involved intentionally ensure that priorities and solutions are driven by the community, with representation, leadership, and decision making by members of the community.8 Equity: The organizations involved work to ensure everyone has the opportunity to be as healthy as possible and center this framing in the processes of building shared purpose, data, financing, and governance. Power dynamics: The organizations involved shift power dynamics between sectors and within communities to ensure underrepresented voices drive change by following the lead of community members who are furthest from opportunity and the organizations those people trust most. Trust: The organizations involved work together and with the community in transparent and honest ways. When these factors and the components are successfully interwoven, the result is a deeply established and fundamentally new way of working together—with staying power to advance health equity. There are many opportunities to ensure that multisector collaborations prioritize and integrate equity,9 and communities across the nation are doing so in myriad ways. No single organization or sector can solve the deep-rooted issues of systemic racism that America faces10; addressing this requires trusting, honest conversations,11 intentional work, and structural change. Establishing working relationships with community-based organizations, including community organizing groups, and rebalancing power dynamics create channels through which collaborative partners can engage those directly affected by aligned multisector efforts. These kinds of approaches helped communities identify pandemic response priorities and address barriers to access and care in underresourced areas, as was the case in Pierce County, Washington. Aligning Sectors Up Close: Pierce County, Washington Elevate Health, an Accountable Communities of Health organization in Pierce County, Washington, brings this approach to life.12 For years, Elevate Health convened health care, public health, and social services partners to transform how they deliver care and services and promote health equity at the community, state, and regional levels. They have well-established components that support aligning participating sectors, including shared data systems and sustainable financing. When the pandemic hit, Elevate Health's existing cross-sector approach made it easier to support at-risk populations and people quarantining after potential exposure to COVID-19. They developed new resources, including screening and risk assessment tools, that enabled community health workers and care coordinators to connect vulnerable and affected community members with immediate medical and social services. What does it look like for people to be better cared for and supported by organizations that are working in alignment with one another? For one patient, it began with a referral to Elevate Health by an emergency department physician after he tested positive for COVID-19. Because the patient was experiencing homelessness and unemployment, partners in Elevate Health's Care Continuum Network provided support during his recovery, including assistance with his needs for housing and employment. Unprecedented Opportunity for Change The pandemic brought widespread unemployment, and millions experienced housing and food insecurity in addition to widespread negative effects on mental health. As we look to the future and examine the long-lasting consequences of the triple crisis of the COVID-19 pandemic, resulting economic struggles, and the ongoing impact of systemic racism, the need for health care, public health, and social services to work together and to follow the lead of the community members they serve only increases. During postpandemic recovery and rebuilding, states and municipalities can use past experiences, relationships, and both existing and new financial investments to more effectively and equitably align in ways that support the goals and needs of people and communities.13 Notably, billions in federal relief and recovery funds can be thoughtfully deployed to begin or strengthen community-led alignment among health care, public health, and social services sectors to maximize the benefits for people who live in the communities they serve.14 Public health departments, community foundations, public health institutes, coalitions, and other organizations can step forward to assist, bringing decades of experience tackling local health problems and their relationships with community members. In Rhode Island, for example, state leaders leveraged a community foundation to lead strategic planning efforts. The Rhode Island Foundation recommended to the governor and general assembly how to direct nearly $1 billion in discretionary American Rescue Plan Act funding. The foundation leveraged its expertise and experience to launch a virtual public engagement process and build a cross-sector steering committee to ensure funding was distributed equitably and inclusively. The pandemic brought sectors together in unparalleled ways. Leaders and practitioners alike can leverage the learnings of the past 2 years to build more resilient and equitable communities for generations to come.

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