By: Nadia Siddiqui, MPH
Health Equity Technical Advisor
Centering health equity is critical to realizing the vision and objectives of Accountable Communities for Health (ACHs)—multi-sector partnerships that seek to improve health outcomes by addressing the social determinants of health and health-related social needs of community members. There is strong evidence that achieving better community health requires intentional and systemic work to promote health equity and close deep and longstanding gaps in social, economic, and health opportunities. As such, the Texas Accountable Communities for Health Initiative (TACHI) has doubled down on efforts to guide and support its six ACH sites in centering and weaving health equity across all its foundational work.
As an initiative of the Episcopal Health Foundation, TACHI has also adopted the Robert Wood Johnson Foundation’s definition of health equity :
Health equity means everyone has a fair and just opportunity to be as healthy as possible. It requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.
On June 15, 2022, the six TACHI teams gathered in Houston, Texas for an in-person convening focused on health equity. As a follow-up to an initial Health Equity 101 online learning session provided to all TACHI sites during the planning phase in 2021, this day-long convening was designed to help sites move beyond a commitment to health equity to putting health equity principles and strategies to action. As such, the teams had an opportunity to:
- Learn about promising practices for advancing health equity across the ACH’s core elements (e.g., governance, community engagement, shared data systems, etc.);
- Engage in collaborative team reflection and discussion of health equity progress and gaps utilizing the TACHI Health Equity Assessment Tool (HEAT); and
- Share with peers their health equity lessons and plans.
Following are key takeaways from the convening that can continue to guide the important work of ACHs in centering and advancing health equity.
It’s a Journey
The pursuit of health equity is a journey at multiple levels – individual, interpersonal, institutional, community and societal. It is not a one-time activity, but a continual process of learning, reflection, and action for all involved at all levels in an ACH. It requires deep listening and engaging in complex conversations with humility, openness, and respect to understand the current and historic context of health inequities, including the legacy of racism, discrimination, and power imbalances. Examples of concrete steps ACHs can take along this journey are to:
- Create spaces for open and honest conversations about health equity
- Build a shared understanding and common language for health equity and related concepts
- Assess baseline health equity capacities, strengths, and gaps to build an action plan
- Integrate principles of health equity explicitly into the shared vision, goals and strategic plan
- Foster a culture of equity by making it a part of everyone’s work—and not just one person’s responsibility
Work Toward Systems Change
Achieving health equity requires broader mindset, policy and systems change to address the root causes of health inequities. Health inequities are produced by underlying inequities in the social determinants of health, which are shaped by institutional policies and laws that are influenced by broader narratives and structural forces, such as racism and discrimination. Taking a systemic approach recognizes that achieving health equity requires work at these multiple, interdependent levels. As such, when designing a portfolio of interventions, ACHs should:
- Identify the root causes of health inequities, exploring the role of racism, power, and policies
- Engage community residents to understand the history, context, and reality of health inequities
- Work with multisector and community partners to design interventions at multiple levels, including not only those that address individual social and health needs (downstream), but also those that address community-level social determinants of health (midstream), and broader structural and policy change (upstream)
- Consider targeted universalism—that is, setting universal community health goals that are achieved through targeted interventions for different groups
- Build shared accountability among partners for equitable processes and outcomes
Share Power with Communities
Through generations of systemic exclusion, marginalization, and disinvestment, many low-income people and communities of color have been excluded from decision-making that impacts their health and well-being. Evidence shows that building and sharing power with communities most impacted by structural and health inequities helps drive meaningful, equitable and lasting change toward improving community health. However, in doing so, ACHs must work with humility, authenticity, and respect for the community’s role and expertise. Following are some ways ACHs can move toward sharing power with communities:
- Assess power dynamics and distribute power equitably by understanding the visible and invisible forces of power:
- Who is at the decision-making table? Who is not?
- Who decides who is at the decision-making table?
- Who decides the agenda and priorities?
- Move beyond informing and consulting communities to building authentic, trusting, and long-term bi-directional relationships that share leadership and expertise
- Include diverse community leaders and members in Governing and Leadership roles
- Provide financial and logistical support to community members to meaningfully engage
Data for Action and Accountability
Shared data and performance measurement are important elements of an ACH, and critical tools to help identify health equity-related needs, prioritize populations, design interventions, monitor progress, make continual improvements, and build accountability. Following are ways in which ACHs can center health equity in data and performance measurement:
- Engage communities as experts at every stage of the data lifecycle (planning, implementation, evaluation)
- Use mixed quantitative and qualitative methods to identify health equity-focused needs
- Develop measurable health equity goals, and monitor the “distance to go” to reach them
- Collect, stratify, monitor, and report data on process and outcome measures by subpopulation groups (e.g., race, ethnicity, language, age, sex, gender identity, income, neighborhood, etc.)
- Create systems to link and share social, health and equity-focused data across sectors
- Increase equity-focused data literacy among multisector partners and community
Setting on a path to achieving health equity is a collective responsibility that everyone involved at all levels in an ACH—funders, leaders, staff, partners, and members—must commit to in principle and action. Going forward, Episcopal Health Foundation remains firmly committed to the pursuit of health equity—a muscle core and essential to the success, sustainability, and impact of ACHs in driving transformational change for better health. As such, TACHI will continue to provide ongoing co-learning opportunities and implementation support for health equity. This includes coalescing a living and evolving toolkit of evidence-informed resources and practices on “how to” operationalize health equity; providing coordinated technical assistance through a multidisciplinary team of subject matter advisors on integrating health equity actions across all the major functions of an ACH (e.g., backbone, governance, shared data, community engagement, etc.); and creating spaces for peer-learning across all TACHI partners. As we move along this journey, we—the team of TACHI partners—recognize we won’t have all the answers, and we may stumble along the way, but we remain steadfast in our commitment to learning and growing together to create healthier, more equitable communities where all have the opportunity to thrive.