Cuyahoga County Uses Health Improvement Process to Lift Up Equity and Racial Inclusion

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Overview

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The Cuyahoga County Board of Health, Ohio, worked with a multisectoral consortium to develop an equity-focused Community Health Improvement Plan (CHIP). Their CHIP identifies health equity as a guiding principle and tackling structural racism as 1 of 4 strategic priorities.


Who Took This On

Cuyahoga County Board of Health, OH


Ways You Can Get Started

  • Map health outcomes and connect them to the historical context of institutional and structural racism
  • Commit to staff and partner equity training using a “head and heart” approach as part of creating a Community Health Improvement Plan

See Advice for Local Health Departments below for more ways to take action.

What Sparked This?

Engaging multiple staff in equity work with Place Matters

Beginning in 2006, the Cuyahoga County Board of Health (CCBH) became actively involved in Cuyahoga County’s Place Matters team, convened by what is now the National Collaborative for Health Equity. The staff who played leadership roles in Place Matters built their own capacity to connect social and environmental factors to health. They also strengthened their relationships with one another and made connections to a national learning community. Key staff people in agency leadership and program oversight included the Deputy Director of Prevention and Wellness, the Director of Organizational Development (formerly the Director of Community Health), and the Health Commissioner.

“Having 3 of us from this agency involved really helped to create a foundation. . . . When we started to learn about equity, we were ready to infuse it throughout [CCBH]. You need to have equity in every layer — it can’t just be leadership and can’t just be program staff.”

Using life expectancy data paired with history to discuss structural racism

In 2009, CCBH partnered with the Alameda County Public Health Department in California to create their first map showing county life expectancy by neighborhood. They found a 24.5-year gap between neighborhoods, with the lowest life expectancies in low-income neighborhoods of color in Cleveland and its first-ring suburbs. This map became a rallying point for further equity work. Subsequently, the Place Matters team commissioned their first health equity report, entitled History Matters: Understanding the Role of Policy, Race and Real Estate in Today’s Geography of Health Equity and Opportunity in Cuyahoga County, which was developed by the Kirwan Institute for the Study of Race & Ethnicity at the Ohio State University. The report shows how institutional racism in housing policy 60 years ago shaped neighborhood opportunities and health outcomes along racial lines today. It was foundational for how CCBH would continue to engage history in the narrative of why tackling structural racism is crucial for health equity work.

Did you know?

Housing policies supported by the Federal Housing Administration and carried out by private banks beginning in the 1930s shaped racial segregation, the racial wealth gap, and health inequities in cities across the country, including Cleveland. For more information on the history of housing policy and its connection to health, see the Cuyahoga County Community Health Improvement Plan, p. 12.

Launching Health Improvement Partnership (HIP)-Cuyahoga 

In 2009, CCBH helped found the HIP-Cuyahoga consortium in order to create the county’s first Community Health Improvement Plan (CHIP). HIP-Cuyahoga’s network has grown from about 50 organizations and a total of 200 individuals in 2009 to more than 100 organizations and over 900 individuals in 2017.

Program Description

HIP-Cuyahoga as the home for transformational thinking about health equity

HIP-Cuyahoga is committed to a shared vision and a common agenda, with health equity as a constant guiding principle, and has identified 4 key approaches as part of their Framework for Action:

  • Perspective Transformation – Building capacity to think, understand, and act differently to make equity and racial inclusion a shared value
  • Collective Impact – Fostering cross-sector collaboration, coordination of partnerships, alignment of priorities and actions, and mobilization of resources
  • Community Engagement – Involving community members in planning, decision making, and actions
  • Health and Equity in All Policies – Incorporating healthier and more equitable decision making across sectors, systems, and policy areas

CCBH acts as the backbone organization for HIP-Cuyahoga within a broader core infrastructure consisting of 2 partnership co-chairs, 7 anchor organizations, and 2 workgroup co-chairs. (See HIP-Cuyahoga’s Structure and Steering Committee for more details.) CCBH’s role is not to lead, but rather to organize administrative efforts such as management of day-to-day operations, fiscal oversight and strategic guidance, and coordination of communications and evaluation.

CCBH’s Deputy Director of Prevention and Wellness serves as the partnership coordinator. HIP-Cuyahoga’s co-chairs, who represent the local nonprofit PolicyBridge and Case Western Reserve University School of Medicine, work in concert with CCBH. This core team supports the Steering Committee and consortium around equity, racial inclusion, and collective impact, and ensures that HIP-Cuyahoga’s activities align with the Framework for Action.

The CCBH Health Commissioner is very engaged in all aspects of HIP-Cuyahoga, serving on the Steering Committee and participating in events, planning meetings, and subcommittee meetings. The CCBH senior leadership team is committed to and engaged in equity capacity–building work that is now being translated from HIP-Cuyahoga back to the agency. HIP-Cuyahoga became the home for transformational thinking about health equity and facilitated infusion of these principles into the CHIP and ultimately CCBH’s own strategic plan.

HIP-Cuyahoga begins creating CHIP

In 2009, CCBH began work on their first CHIP. The Public Health Accreditation Board requires a CHIP for local health department accreditation, and a CHIP provides an opportunity to align efforts to address the county’s most pressing health needs. HIP-Cuyahoga conducted the process using CDC and NACCHO’s Mobilizing for Action through Planning and Partnership (MAPP) framework.

From 2009 to 2012, HIP-Cuyahoga completed the visioning and assessment phases of the MAPP process. Since 2012, the consortium has received crucial funding from the Saint Luke’s Foundation of Cleveland, Mt. Sinai Health Care Foundation, NACCHO, the George Gund Foundation, and CDC (Racial and Ethnic Approaches for Community Health grant) to accelerate the work. This funding has supported implementation of action plans, as well as key infrastructure and operations costs, including but not limited to staff time, communications, facilities, consultants, and travel. Partners provided substantial in-kind support.

Early in the planning process, HIP-Cuyahoga partners came primarily from the public health system, but as the Steering Committee thought about selecting priority issues and strategies for the CHIP, they intentionally engaged a more diverse group. Given that members brought a wide range of backgrounds regarding equity work, HIP-Cuyahoga used their new funding to bring on CommonHealth ACTION (CHA) as a consultant to support the consortium in moving beyond the dominant narrative of traditional health and health care priorities. CommonHealth ACTION, a national public health organization, provided health equity training at meetings and convenings, facilitated group input and voting processes, and supported strategic planning for over 3 years.

The “head and heart” approach builds understanding of structural racism as a public health issue

In 2013 CommonHealth ACTION led a full-day equity workshop that all HIP-Cuyahoga participants were required to attend before officially moving into selecting priority areas for the CHIP. The training included:

  • Examining Cuyahoga County’s history of racial injustice, particularly how federal housing policy contributed to racial segregation and health inequities that persist to this day
  • Descriptions and mechanisms to explain how racism, privilege, and oppression affect health

CCBH’s Deputy Director of Prevention and Wellness described the training as “transformational,” and key to building shared values among the group, in part because it used a “head and heart” approach. Participants were asked not only to learn intellectually why addressing racism and oppression matters for public health — to use their heads — but also to make a personal connection to justice and equity, with their hearts. The Deputy Director also acknowledged that this work challenged participants, as people who are often more comfortable with data were asked to move outside their traditional fields to confront longstanding societal inequities.

CommonHealth ACTION facilitated the selection of the CHIP’s strategic issues and key priorities through an equity lens, consistently returning to these guiding questions:

  • What are the historical impacts of policies in our community?
  • How do these policies impact people’s opportunities to be healthy today?
  • What resources are at our disposal?
  • How do we make sure that we advance the collective understanding of these issues across our community?

Ultimately, from a list of 14 potential strategic priorities, HIP-Cuyahoga chose 4:

  • Healthy Eating and Active Living – Increase access and opportunities for improved nutrition and physical activity
  • Chronic Disease Management – Improve chronic disease management through the engagement of various sectors
  • Linking Clinical and Public Health – Improve coordination between clinical care and public health to improve population health
  • Eliminate Structural Racism – Eliminate systemic and structural barriers for communities of color to improve conditions and opportunities impacting health

Equity leaders within CCBH agreed that eliminating structural racism likely wouldn’t have risen to the top of the priority list without the shared training experience of HIP-Cuyahoga members. The “head and heart” approach is also evident in the final Community Health Improvement Plan, released in 2015, which begins with personal letters from the Steering Committee co-chairs about their commitment to health equity work.

CCBH infuses health equity into their strategic plan

CCBH’s participation in HIP-Cuyahoga ultimately helped bring equity to the forefront of the department’s 2016–2020 Strategic Plan. Staff who had participated in developing the CHIP brought in CHA to do an all-staff training in 2014, and they facilitated exercises at a board retreat that year as well.

The goals of these trainings included expanding knowledge of how racism, privilege, and oppression impact health, increasing staff’s ability to see how the determinants of health and equity affect the people and communities they serve, and creating a shared understanding of equity among CCBH leadership and staff. The workshop was given twice over the course of 2 days, with agency staff and leadership divided into 2 groups and assigned to participate on 1 of the days. The final Strategic Plan lifts up equity as a core value, and the framing shows a significant shift from the previous plan, as seen in Table 1.

Table 1: Comparing the Mission, Vision, and Values in CCBH’s previous and most recent strategic plan

2011–2015 Strategic Plan 2016–2020 Strategic Plan
Mission To prevent disease and injury, promote positive health outcomes, and provide critical services to improve the health status of the community To work in partnership with the community to protect and improve the health and well-being of everyone in Cuyahoga County
Vision To optimize the public health status of the community through transformational programming that creates a clear line of sight between what we do every day and how the organization performs To create the conditions in which all people who live, learn, work, and play in Cuyahoga County have the opportunity to be healthy
Core Values Accountability, community service, integrity, leadership, and partnership Health equity, integrity, partnership, and innovation

 

Future Steps

HIP-Cuyahoga

The CHIP established an Eliminating Structural Racism Subcommittee within HIP-Cuyahoga (along with subcommittees for each of the priority areas). This committee has ambitious goals (see CHIP, p. 29) that include both continuing their efforts to shape member organizations’ capacity to use a structural racism lens in their work in the short term, and identifying policies and practices that address structural racism, racial inclusion, and cultural competence in the longer term.

Members of the Steering Committee are hosting a series of roundtable discussions that bring together key policy leaders – local and regional elected officials, as well as organizational leaders, to explore opportunities to align interests, capacity, values, partnerships, and resources, around policy action areas that can foster sustainable community change and advance a culture of health and equity in Cuyahoga County (See http://hipcuyahoga.org/policy-makers/  for more details)

HIP-Cuyahoga is embarking on an evaluation planning process using an equity lens. They will establish clear outcomes and associated progress indicators and a system for tracking progress, and assess the consortium’s capacity to implement the evaluation plan.

HIP-Cuyahoga will collectively move through a business planning process in order to develop a transparent resource and sustainability plan that considers both short- and long-term funding and resource needs.

CCBH

Internally, CCBH continues to shape the agency’s strategic approach to integrating equity, diversity, and inclusion into the organizational culture, policies, practices, and programs.

Advice for Local Health Departments

  • Take a “head and heart” approach

    Public health professionals and government employees are often more comfortable discussing data and programming than their personal connections to health equity. However, engaging the “heart” is key to developing shared values and vision within staff and among external partners.

  • Engage with your community’s history to understand the roots of inequities

    Exploring Cuyahoga County’s long history of racial exclusion through housing policy helped HIP-Cuyahoga participants come together in understanding that structural racism is a foundational cause of health inequity. Rooting historical analysis into the context of your community’s reality helps make these issues more concrete and less abstract.

  • Develop a plan for financial sustainability

    In addition to putting your efforts into building partnerships and a new narrative for health equity, make sure to also create a plan for financial resources and sustainability. Routinely revisit your financial status and outlook, and try to balance short-term and long-term funding for equity work.

Strategic practices leveraged in this case study

Develop a Shared Analysis
Develop a Shared Analysis
Confront the Root Causes
Confront the Root Causes
Build Organizational Capacity
Build Organizational Capacity
Change the Conversation
Change the Conversation
Build Community Alliances
Build Community Alliances

Additional Resources

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