What Sparked This?

Inequities data sparks creation of Health Commission and Community Health Improvement Plan

In 2000, the new Kansas City, MO, Director of Health and department staff found that White residents of Kansas City lived on average 6.5 years longer than African American residents and that roughly half of the city’s annual deaths could be attributed to social factors such as segregation, poverty, violence, and a lack of education. These stunning findings led to the creation of the Mayor’s Kansas City Health Commission and the launch of the City’s first Community Health Improvement Plan (CHIP).

KCMOHD Director attends CCO training, inspired by their community organizing model

Recognizing that KCMOHD community engagement efforts were siloed and fairly traditional, the Director sought out a community engagement partner to help the Health Department improve its efforts. In 2007, the Director attended a meeting organized by CCO, a primarily ecumenical faith-based community organizing group with a 39-year history of working toward a more socially just society. Very impressed with their political savvy, the Director learned more about the organization and their values. CCO’s organizing strategy stated that, to be effective, organizations have to develop one-on-one relationships with individuals, and that those relationships engendered the power to transform oneself, one’s community, and society at large.

CCO chosen as community engagement partner

Although there were several well-known community organizing groups in Kansas City, CCO was specifically selected by KCMOHD due to their ability to mobilize people around important issues and command influence in spheres where health departments are traditionally limited. With over 100 faith-based leaders and their respective congregations as members, CCO had the ability to take the pulse of the community, develop local endogenous leaders, and mobilize them around key issues. At the same time, CCO was chosen because of their skill in working across the political spectrum in ways that lead to more fruitful, less divisive exchanges than might otherwise occur.

Program Description

5-year “courtship” to bring data and power together

After initial encounters at meetings and community events, KCMOHD and CCO recognized that they were promoting similar causes. The KCMOHD Director recalls a presentation by the former Alameda County Health Officer where he described public health is a social justice enterprise, where public health can bring data and objective facts, and community organizers can bring power. That framework, which emphasizes the importance of social movements, has significantly informed the relationships between KCMOHD and CCO. As noted by CCO’s Executive Director, “CCO is in the business of advocacy. Our advocacy is informed by knowledge from the community as well as from data and surveys. The health department can use data and research to make the argument that raising the minimum wage improves quality and length of life, and it’s up to CCO to get residents to show up, share their stories, and support the policy.” The KCMOHD Director agreed, stating, “As public health and an institutional agency, we can work through the bureaucracy and the outside groups can apply the pressure.”

In 2010, CCO invited the Director of KCMOHD to join them at the first National Community Organizing and Public Health Exploratory Meeting. This meeting reaffirmed to the leaders of both organizations that they shared values and mutually beneficial and complementary skill sets that could advance a broader social agenda. Shortly after this meeting, the 2 groups decided to formalize their partnership and drafted a Memorandum of Understanding (MOU) in 2011, which was officially signed in the spring of 2012.

MOU developed, defining roles, responsibilities, and joint objectives

The KCMOHD-CCO MOU was developed to create a direct and clearly defined relationship between the Health Department and their community partner. The MOU defined each party’s roles and responsibilities and joint objectives. The framework for the collaboration centered on 5 key areas:

(1) A shared vision: Creation of conditions for good health for all

(2) A shared focus: Elimination of health inequities based on race, class, gender, and power

(3) Alignment: Local public health agencies with faith-based communities, neighborhood associations, labor groups, and more

(4) A shared space: CCO is co-located within the Health Department

(5) Shared outcomes and evaluation

Their joint objectives are grouped into 3 main categories: building capacity in the fields of public health and community organizing, engaging priority communities, and achieving health impact outcomes.

MOU implementation and cost savings

After a few years of working within the MOU guidelines and evaluating their processes, the MOU was updated in January 2016 to strengthen the partnership and to make the objectives and practices more specific. The KCMOHD Director notes that “the MOU process was easy to execute, requiring only my approval and that of CCO’s Executive Director, and has been affordable with minimal costs associated with the execution of contracts and a pledged membership to CCO by KCMOHD. Although both organizations did eventually hire additional full-time staff as a result of this partnership, it is difficult to say how much extra cost that entailed. Much of that cost is offset by the additional impact we are having in the community through advocacy, grants, etc.”

According to KCMOHD, the MOU enabled the Health Department to function as if it had a community organizing division without the cost of hiring, training, and maintaining one. It is estimated that this process has saved KCMOHD upward of $1.5 million annually while still creating the same level of influence and change as they could have achieved on their own.

Sharing office space facilitates trainings and communication

One of the MOU agreements was that the 2 organizations would share office space. For 15 years, KCMOHD had dedicated a specific office space within the Health Department building for community partnership incubation. Throughout the years, different community-based organizations utilized this space to collaborate with specific Health Department staff on topics related to tobacco, asthma, and other issues.

In 2012, CCO was told that they needed to move offices. KCMOHD and CCO leaders realized that co-locating their teams could facilitate deeper relationship building, as well as increase and improve communication between the 2 groups. As a result, CCO moved into the Health Department, which made joint trainings, cross-trainings, agency education, and day-to-day communications easier and more fluid. In addition, co-location provided cost savings for both organizations, which is critical in a city with competition for philanthropic dollars.

How the 2 groups work together

As described in their NACCHO Model Practice description, “A health-related issue can be identified in many ways. It could be from the health department through evaluating new data; it could be from CCO through talking to community groups; it could be from the Health Commission through discussions with city council or other organizations. Once an issue is identified, the KCMOHD and CCO meet to discuss how it is impacting the health of the community. Key players and influential community leaders are identified (such as the Health Commission), a plan for influence around the issue is created using grassroots community organizing tactics, and data needs and information gaps are determined. Then a strategy is formed. Each agency works together and within their sphere of influence to create a movement that is stronger than either entity could achieve alone. The MOU acts as both a tool and a roadmap as the two agencies invest sufficient time and resources to achieve the intended health equity and social justice outcome within the targeted area/population.”

Development of short-term and long-term objectives

KCMOHD and CCO developed short-term and long-term objectives that they hope to achieve together. Many of these objectives are now included as top priorities in the Kansas City Health Commission’s 2016–2021 Community Health Improvement Plan (CHIP). Examples of the objectives include improving employment opportunities for people with a felony conviction, raising the minimum wage and high school graduation rates, and lowering unemployment rates and differences in life expectancy across zip codes.

KCMOHD builds capacity to support the collaboration

Over time, KCMOHD has built internal capacity to facilitate and support collaboration with CCO and other community organizers. Activities include:

• Requiring all supervisory Health Department staff to conduct a minimum of 3 one-on-one meetings with people outside of the Department per year to build relationships
• Adopting a new software program to track the one-on-one meetings, since it is required for performance evaluations
• Adding 2 more public health statisticians to provide data support to health equity work across the city
• Organizing trainings about community organizing and relationship building for all incoming KCMOHD staff and those participating in specific Department-wide workgroups
• Sponsoring and hosting public meetings at the Health Department to discuss specific policy decisions under consideration by City Council and the Mayor, such as raising the minimum wage

Outcomes and Impacts

• Social justice and health equity now part of daily conversation for KCMOHD

  As a result of this solidified partnership, both parties have seen incalculable rewards. Social justice and health equity are now part of the daily conversation for KCMOHD. CCO helped mobilize the community and has expanded KCMOHD’s sphere of influence. KCMOHD has provided CCO with important data and networking that are key to their mutual successes. After 6 years of informal collaboration and 4 years of working in an official partnership, all of their mutual objectives (as outlined in the MOU) are either complete or in progress.

• Organizers use messages about quality of life and life expectancy to highlight where to target limited resources

  As noted by the CCO Executive Director, through this collaboration, the way CCO does their work has changed, taking on greater purpose and urgency. He notes that CCO now uses health equity in a lot of their messaging, and quality of life and life expectancy are common themes in their work. For example, they invite policy makers to look at issues through a public health and equity lens to see where people in the community are struggling. CCO acknowledges there are limited resources, but emphasizes that those limited resources should be used in communities with the lowest life expectancy.

• CHIP focuses on social determinants

  Unlike CHIPs in other jurisdictions, which primarily focus on indicators of clinical care, the 2016 KC-CHIP focuses largely on the social determinants of health such as violence, education, economic opportunity, the built environment, mental health, and preventive care. As noted by the Manager of KCMOHD’s Community Engagement, Policy and Accountability division, the Health Commission “owns the creation of the CHIP, but we don’t own the CHIP — it is the entire city’s plan for how to improve community health. Once the City Council adopted the CHIP, it became clear that everyone else had to be involved in order to achieve these objectives.”

• Life expectancy included in City’s business plan, impacting city policies

  As described in the Kansas City LifeX case study, KCMOHD successfully advocated for the inclusion of life expectancy in the City’s 2017–2022 business plan. Specifically, one of the stated departmental strategic objectives is to “Increase overall life expectancy and reduce health inequities in the zip codes with the lowest life expectancy . . and the additional zip codes with the least improvement in life expectancy.” Inclusion of this objective led to the Kansas City LifeX Summit, which has resulted in city agencies reflecting on what they can do to help improve life expectancy in specific zip codes.

• Shared leadership achieved

  Using the Community Engagement Continuum as a barometer for measuring the strength and effectiveness of community engagement outcomes, KCMOHD and CCO have found that after working together for almost a decade, they have achieved the fifth and highest level: shared leadership. This was achieved by growing community involvement, impact, trust, and communication. The KCMOHD Director notes that “the importance of reaching this level is that we see broader health outcomes affecting a broader community than we did when we were working in a more siloed and narrow approach.” Another aspect of shared leadership is that the directors of both organizations are in the governing bodies of the other’s organization — the KCMOHD Director is a member of the CCO Board of Directors, and the CCO Executive Director is the Vice Chair of the Kansas City Health Commission.

• Property tax funding supports prevention and health care access

  In 2014, CCO, with support from KCMOHD and other citywide stakeholders, achieved 70% voter approval to continue a citywide property tax for 9 years and allocate $15 million annually for illness and preventive health care for indigent populations.

• Numerous policy wins of short-term and long-term target measures

  The full list of collaboration accomplishments is available in the NACCHO 2017 Model Practice Notable achievements include:

  • Removing mandatory disclosure of criminal history on job applications in Kansas City, MO (2013), Jackson County (2016), and the State of Missouri (2015)
  • Removing the prohibition of providing SNAP benefits to those convicted of drug-related crimes (2014)
  • City Council voted twice to approve an increase to the living wage (2015); however, that measure was preempted by the state, so CCO and KCMOHD are now considering a statewide ballot to increase the living wage (2018)
  • The City of Kansas City, Missouri, now offers 6–8 weeks of paid parental leave following birth or adoption (2016), via a vote of the City Council
  • Engaging more than 1,500 people in a campaign to view the Raising of America documentary and commit to improving health for the city’s youth (2014)
  • Increasing the number of banking institutions willing to provide small loans at reasonable interest rates (2012)

• Notable improvements in the social determinants of health in Kansas City

  • Unemployment rates have decreased for all minority groups, and the gaps between groups have reduced
  • The difference in life expectancy at birth between White and Black residents has decreased from 6.5 years to 5 years, and life expectancy has increased for all groups
  • Geographic racial segregation has decreased by approximately 7%
  • The percentage of people living below the poverty level has decreased for all racial/ethnic groups (except those who classify themselves as “some other race”), and the gap between ethnic groups has also decreased

• Awards/recognition by others

  To date, KCMOHD is the only health department in the country to receive PHAB accreditation, NACCHO’s Local Health Department of the Year Award, and the RWJF Culture of Health Prize. KCMOHD has also been recognized by the Aetna Foundation, the American Public Health Association, the National Association of Counties, and the National League of Cities for their health equity work.

Future Steps

Both KCMOHD and CCO are committed to the sustainability of their partnership and work. Although pleased with their success, they recognize that much more is needed to create a healthier and more equitable Kansas City. Some of the initiatives in the coming years will include:

• Establishing a system of early voting in KCMO and its counties
• Continuing to work to expand Medicaid
• Helping establish a regional and eventually statewide prescription drug monitoring program
• Passing a property tax to fund universal, quality public education for 3- and 4-year-olds
• Pursuing a voter-approved rental housing inspection ordinance
• Working to pass legislation that caps the rate on payday loans
• Continuing work toward a minimum living wage
• Further disseminating lessons learned and impacts from their shared collaboration

Advice for Local Health Departments

• MOUs create accountability and transparency

  While aspects of the KCMOHD-CCO collaboration might have been achieved without a formal MOU, the MOU created accountability for each partner. Each entity accepted the responsibilities that came with a formalized and strategic scope of work. The MOU, as a tool, clearly delineated roles and responsibilities, leaving little question as to the expectations of each organization.

• Operate within your own area of expertise and strength

  While being innovative is beneficial, you do not need to reinvent the wheel. It is important to identify key individuals and entities that can help with community organizing and accessing people in power to influence social change. Operate within your own expertise and strength; allow your organization to utilize others to diversify your skills, tools, resources, and reach.

• Partnerships take time, commitment, and systems thinking to effect long-term change

  KCMOHD and CCO have achieved a lot together, but it has been a long journey. Transformative change happens over time and must be guided by a vision of where you want to go and how to get there with others. Having a vision for what needs to be different 5 to 10 years from now can help emphasize the importance of systems thinking. 

• Showing up is important

  Partnerships are based on relationships, and relationships are based on time spent together. It’s important for health department staff to show up and support community organizers in whatever ways you can, even if that means taking a vacation day to attend the minimum wage rally, or going to a community event in your personal time. It is also important to be strategic and selective, and to avoid conflicts of interest. But health department staff are also community members, and they have extended families and friends who can help rally others for key decisions and events.

• Keep community organizing external

  Community organizers need to remain independent to be effective. Remember that even if you are located in the same building and are fighting for the same causes, you have different strengths. In your communications and collaborations with the community, it should be clear that the community organizing is external to the organization.

• Start with their issues, not yours

  The quickest way to fail is to think that community organizers are going to take on your health issues. You need to go to community organizers and understand the pain that they and their constituencies are feeling. Go with them, listen to what they have to say, show them data they may not be aware of, help provide additional legitimacy to their stories and concerns, and help them understand how to navigate government bureaucracy. As noted by the CCO Executive Director, community organizing has a goal of showing up and listening. When KCMOHD and other government staff listen, there is an opportunity for true connection between the individuals and their organizations.

Strategic practices leveraged in this case study

Share Power with Communities

Confront the Root Causes

Mobilize Data, Research, & Evaluation

Build Community Alliances

Engage in Movements

Additional Resources

• Faith in Action (formerly PICO)
• Community Organizing: Practice, Research, and Policy Implications
• Doing Justice: Congregations and Community Organizing