What Sparked This?

Health department merger creates opportunities to learn about social determinants of health

In 2008, the City of Madison Health Department and the Division of Public Health within Dane County Human Services Department merged to form an independent department of public health, known as Public Health Madison & Dane County (PHMDC). With this merger, the Department identified efficiencies in how to provide services, and a small group of public health nurses was encouraged to think about how to practice public health differently using a population health and social determinants of health perspective. These staff were supported to think about how to manage individual service delivery programs (e.g., for people with TB or HIV/AIDS, pregnant women, etc.) differently as well as how to engage communities of people differently to address health concerns. At that time in the new organization’s development, however, this effort was not paired with resources or an understanding of how to do the work in an intentional data-driven way.

Health equity team forms but not integrated into department-wide work

From these initial efforts, the Community Health Division formed a health equity team to experiment with a number of different programs. During this time, there was no strategic plan, there were many leadership transitions, and there was not a clear framework for how to build capacity at the institutional level. As noted by the Director, “There was a lot of trying something new here, something new there, in a one-off kind of way. This created confusion among staff about whether the health equity work was an additional effort or core to the work they were doing. People asked — are you asking us to do more?”

The health equity team used the BARHII Organizational Self-Assessment Toolkit to help identify the skills, organizational practices, and infrastructure needed to address health equity. The assessment involved doing a survey of staff and collaborating partners, staff focus groups, interviews with management, and a review of internal documents and human resources processes. The self-assessment helped PHMDC staff realize that:

• Health and racial equity needed to be embedded across the organization, not just held or enacted by a few individuals
• The organization needed to support learning to advance practice
• They needed to use data to drive their actions
• They needed a baseline understanding of what it meant to advance health equity so they could hold each other accountable

Health equity staff hired to embed equity in organization

Through this process, PHMDC staff recognized that if they were going to be serious about advancing health equity, they needed to be staffed and structured differently. After an internal reorganization, 2 health equity coordinator positions were created in the Workforce Development Team of the Operations Unit, with the vision that this was the best place to build capacity and resources for the whole organization. The coordinators’ primary responsibilities were to:

• Build a framework for capacity building in a systematic way across all units of the health department
• Work with city and county partners to foster racial equity and social justice throughout government systems and practice

Data report creates groundswell in Madison

Soon after the first health equity coordinator started, a community partner organization, the Wisconsin Council on Children and Families, released the Race to Equity baseline report, which highlighted significant health disparities between African American and White populations in Madison. The mayor and elected officials asked PHMDC and the City Department of Civil Rights to develop recommendations for what an equity plan for the city would look like. The Department’s first step was to establish an interdepartmental team initially involving half and later nearly all city agencies, which turned into Madison’s Racial and Equity Social Justice Initiative (RESJI). Meanwhile, based on a request from the Dane County Executive and County Board, PHMDC’s other health equity coordinator was working with the Dane County government to build and staff a similar initiative, which became the Dane County Racial Equity and Social Justice Initiative. This initiative now operates from the Tamara D. Grigsby Office of Equity and Inclusion, which was created in 2016. Through these processes, the City of Madison, Dane County, and PHMDC staff began to work with staff from the Government Alliance on Race and Equity.

Interagency team develops shared racial equity analysis

The health equity coordinators noted that much of their early work was devoted to diving into the Madison and Dane County work and building on the groundswell of political and organizational momentum. One of the coordinators noted, “We were very fortunate that when the request came from the Mayor, we were ready to say, ‘Let us help lead this.’” Working together under the elected officials’ request, the city agencies had an understanding that they were going to learn together about what was working in other jurisdictions, what was currently happening in the city, and what tools they could use to help improve their practice. They would also co-create a new vision and strategy for embedding racial equity across Madison city government.

In 2015 and 2016, the city and county hired full-time staff to facilitate their processes moving forward. This then freed up the health equity coordinators to focus more on internal work within PHMDC while continuing to support the City and County efforts.

Program Description

Building off Madison and Dane County momentum, PHMDC staff were excited to build internal capacity within PHMDC to advance racial and health equity. The health equity coordinators noted that being a part of GARE gave PHDMC more credibility and resources as they started their internal process. Specifically, they were able to bring together people from GARE and other jurisdictions to share their learnings. Local community partners (e.g., YWCA) helped make the work more concrete and make it clear that PHDMC was not doing this alone. PHMDC’s internal capacity building process involves the following:

Professional development

To support transformational learning, PHMDC organized a series of learning and discussion groups to start normalizing conversations about race and equity across the health department. All staff were encouraged to attend but participation was not mandatory. Over the first 18 months that these sessions were offered, roughly one-quarter to one-third of all PHMDC staff participated.

Health equity staff worked with university and community partners who were doing racial equity work in their respective organizations to develop and share training materials, lessons learned, and facilitation tips.

The goal of these sessions was to develop a groundswell of people who were curious about how to embed race and equity into the health department. Some participants already had some knowledge about these topics, while others were new to the issues. The Director and health equity staff were clear about what they were hoping to achieve, and also clear that it would be a collaborative, iterative, and lengthy process to move toward their “North Star.”

Strategic plan

Starting in spring 2015, PHMDC began to develop a strategic plan to embed racial equity across the health department. To develop the plan, they realized they needed input from across the organization — from managers and supervisors to front-line staff — as well as from the outside community. To achieve this, PHMDC:

• Conducted an organizational strengths, weaknesses, opportunities, and challenges assessment
• Conducted an analysis of community population and health data
• Considered alignment with state and national prevention strategies
• Sought feedback from leadership, staff, and stakeholders about what worked well and areas for improvement

Equity is embedded throughout the 2016–2020 PHMDC Strategic Plan — clearly articulated in the values and strategic priorities guiding the organization, in community goals to address social determinants of health, and in internal goals to become a highly effective organization that improves “the health of our community by committing to equity, inclusion, and antiracism in our work.”

Through the strategic planning process, PHMDC staff realized that to achieve their “North Star” of embedding racial equity in their public health practice, they needed to have an internal, interdivisional, multidisciplinary team involving staff from all across the health department to help build understanding and buy-in for sustainable systems change.

Work with staff to develop team vision

Prior to recruiting members for the internal team, the Director worked with program supervisors, division directors, and health equity coordinators to help develop the team’s purpose, goals, and objectives. This co-creation was important to advance the understanding that racial equity work is foundational in informing how the health department should operate at program, division, and department levels to impact community health.

Although some understood this shift as foundational, others expressed concerns about how the work would balance with existing responsibilities. The Director explained that the goal of creating the team was to build capacity, learning, and skills to ensure people were equipped to do the work. Specifically, by co-creating the team together, they would ensure that it functioned in a way that incorporated existing responsibilities and also moved toward organizational transformation.

Internal racial equity team formed

In spring 2016, the health equity coordinators conducted agency-wide recruitment for the team. They were very clear that they wanted a diverse team that was multiracial, had varying amounts of time working for the health department, and had varying amounts of positional authority and diverse job descriptions. The Director made sure that division managers signed off on staff commitments to the team. She acknowledged that although there was agreement with management about signing off on participation, there are still some tensions about how to balance existing work and the racial equity work.

The first team was comprised of 15 people, who committed to participating for 1 year and dedicating 8 to 10 hours per month. In the second year, members from the first cohort could continue participating, participate in a lesser role, or opt out. The 2017 team currently has 30 people, which includes a mix of first-year participants and new participants.

The team is organized into 5 workgroups: 1) Professional Development; 2) Assessment and Evaluation; 3) Communication; 4) Implementation; and 5) Community Connections. Although the health equity coordinators facilitate and lead the internal team, there is no single supervisor or leader — decisions are made through consensus and conversation.

Organizational assessment and evaluation conducted

To ensure quality evaluation and assessment during the team- and capacity-building process, PHMDC allocated funds for a University of Wisconsin evaluator to create an organizational self-assessment survey. Drawing on existing surveys and frameworks from the Coalition of Communities of Color, BARHII, and others, this self-assessment survey was intended to establish a baseline of current readiness and practice for health and racial equity work, and to help set realistic goals and benchmarks to monitor progress.

Outcomes and Impacts

• Using racial equity tools in specific projects:

  To put theory into practice, a subgroup of the Implementation Workgroup has begun offering technical assistance to staff across the department, utilizing racial equity analysis tools on a series of projects. Applying racial equity analysis to policy and program decisions fosters transparent and collaborative consideration of potential impacts, particularly on communities of color and other marginalized groups, and allows decision makers to avoid negative impacts and unintended consequences before they occur. The tools also help to engage stakeholders in developing proactive solutions that focus on those most impacted while maximizing benefits for all.

• Putting racial equity into practice at individual program level:

  Recognizing that they could not keep doing one-off projects, the Implementation Workgroup looked into how they could do more across programs. To begin, the workgroup is doing a pilot collaboration with the tuberculosis program to work with its staff to identify short- and long-term changes in their policies, client interactions, and plans. From this pilot, the program will develop a plan articulating new approaches to incorporating racial equity into their work. Presuming the pilot works well, the implementation team will seek to replicate the process with all health department programs.

• Learning through practice:

  Health equity staff note that many people have said that this work is uncomfortable, or questioned its necessity or applicability to them. But interacting with others has provided an opportunity for staff to see the value of the new practices and resulted in increased engagement, making the experiential learning component critical for gaining buy-in and as a tool for professional development.

• Improved culture and climate in the department:

  Staff of color have noted a new feeling of institutional commitment to the community and to those who are disproportionately impacted by inequities. This has impacted their work, as well as the lives of those in the community.

• Increased ability to influence policy and practice in and outside the health department:

  Through this work, PHMDC has more capacity and skilled staff who are able to provide technical assistance and influence policy in many different ways at the city level, and in more limited ways at the county level. Health and racial equity are included in policy development and in the creation of plans by the parks department, planning department, police department, and others. Health department staff now staff the Madison Food Policy Council and other policy committees. The community is being engaged differently and in more meaningful ways.

Future Steps

Building on the lessons learned, PHMDC is working to expand the professional development workshops to make them both mandatory and more accessible. They are exploring doing “equity warm ups” and building from the City of Madison’s 3-part series to train all city staff on health equity. PHMDC is planning to launch this new professional development series in July 2017 as part of their performance evaluation process, which will help push them closer toward being aligned for accreditation. To date, they have piloted the workshop with 1 division and added a specific component on racial equity. PHMDC staff are starting with professional development because it is a very tangible step, but their vision is to implement numerous strategies as part of a more comprehensive approach.

Advice for Local Health Departments

• Start with co-learning

  The whole premise of organizational transformation is that people learn with and from each other, and work together to change the culture and practice. Start by talking to other people and explain where you hope to end up. There is no such thing as over-communication. Communicating again and again helps ensure everyone is on the same page.

• Value others’ work and personal experiences

  When talking about organizational change, it is easy for people to feel excluded and not valued for the work they do. It is critically important for everyone to feel valued and understand that there is so much institutional wisdom and relationships that each person brings — with clients, with people, with community organizations and businesses — that organizational transformation requires. At the same time, it is helpful to take inequities out of the conceptual and talk about one’s community, family, and friends. Be specific and concrete about how staff, as individuals and in their families, are affected by health inequities.

• Transformation won’t happen overnight

  It is important to be clear with staff and decision makers that it took a long time for communities to get to where they are — eliminating inequities won’t happen overnight. Transformation takes time, patience, and resources. Communities learn along the way through practice.

• For true transformational change, everyone needs to be involved

  PHMDC found that if there is a perception that someone else is doing the racial and equity work, it absolves everyone else from perceived or real responsibility for participating. There has to be shared understanding and shared ownership. Developing a culture of accountability is difficult, but critical for developing true equity across your organization.  Front-line staff of many organizations say they are limited in what they can achieve because they do not have leadership buy-in. At some level, there has to be top-level institutional commitment to achieve transformational change.

• Don’t be afraid even though it gets messy and uncomfortable

  Messiness is not failing. Transformation is necessarily uncomfortable, because if it’s not uncomfortable, you are not changing the status quo.

Strategic practices leveraged in this case study

Develop a Shared Analysis

Change Internal Practices and Processes

Develop Leadership and Support Innovation

Build Organizational Capacity

Mobilize Data, Research, & Evaluation

Additional Resources

• BARHII Framework on Social Inequities and Health
• YWCA Eliminating Racism, Empowering Women
• Coalition of Communities of Color