The San Francisco Department of Public Health, California, created the Program on Health, Equity and Sustainability (PHES) through increased staff efficiency, autonomy, and innovation with the goal of working in partnership with residents, public agencies, and private organizations to advance healthy environments and social justice. (The perspective expressed in this case study is not that of SFDPH and represents the perspective of a former Director and former staff.)
Who Took This On
Environmental Health Branch, San Francisco Department of Public Health, CA
Ways You Can Get Started
- Create a 90/10 or 80/20 policy — if staff finish their work in 80–90% of the time, they can use the remaining 10–20% to work on a project that will improve health equity
- Identify inefficiencies in organizational practice and re-appropriate staff positions for health equity
- Work closely with community organizers trying to address the social determinants of health to identify opportunities for collaboration
See Advice for Local Health Departments below for more ways to take action.
What Sparked This?
New Environmental Health Director identifies inefficiencies and untapped potential
In 1998, the Environmental Health Branch (EHB) Director at the San Francisco Department of Public Health (SFDPH) started his new position amid management-staff tension. Some staff were frustrated with the lack of accountability across the organization, and others felt existing management limited opportunities for growth and innovation. The Director held staff listening sessions, shadowed EHB staff, and developed an Organizational Improvement Workgroup. Through this process, EHB identified a number of places where the organization was working inefficiently — e.g., 3 staff members were doing similar billing activities for hazardous waste management and yet didn’t follow up with businesses to recoup the fees — and committed to reduce those inefficiencies and create a more innovative staff culture.
Branch reputation changes to be more efficient, effective, and fair
The Director started working to change the internal culture and public reputation of EHB to be effective, fair, honest, and inscrutable. Rather than allowing some businesses to not pay their fees, EHB staff began withholding health permits until payment was received. When visible and reasonable requests came in, particularly from elected officials, the Director tried to quickly respond and resolve the problem in a transparent manner. EHB staff also established performance metrics for all mandated programs to advance internal transparency and accountability, and provide clear measures of staff expectations. Improving the bureau’s reputation provided the Director and staff greater latitude and autonomy to take on work within the Department.
Creating a culture of staff innovation and “passion projects”
Recognizing that autonomy is an important component of job satisfaction, the EHB Director sought to create an internal culture enabling staff to pursue their passions independently. He established an informal policy that if a staff person finished all of their assigned work (e.g., inspected 300 restaurants in a year), they could spend up to 1 day a week moving their own ideas forward about how to improve environmental health.
The Director supported staff by lending organizational authority, resources, and, where possible, funding. For example, one environmental health inspector doing lead inspections stated that she wanted to work with immigrants on occupational safety and health. In her inspections, she saw many day laborers being exposed to lead paint, and she wanted to provide trainings about how to limit their exposure to lead. The Director supported her initiative and secured $5,000 from the EHB equipment budget to do the trainings and purchase protective equipment for the workers. These projects not only increased staff satisfaction and engagement, but also improved environmental health practice.
Cost savings and penalty fines reinvested in health equity
EHB leadership also tightened permit accountability and updated the permit fee structure by tying fees to their actual regulatory costs. In the first year after these changes, EHB raised $1.6 million in permit fees revenue. With this increased revenue, the EHB Director and the Director of Health created 2 new epidemiologist positions for health equity within EHB. At the same time, the Director identified other opportunities to invest environmental health resources into advancing health equity. For example, when individuals are taken to court and found guilty of violating hazardous materials and waste disposal laws, they are fined a penalty, a portion of which goes to an EHB account for the “protection and prevention of environmental health.” The EHB Director interpreted work on the social determinants of health as falling within the scope of this prevention fund, and used the penalties to fund the Eastern Neighborhoods Community Health Impact Assessment (ENCHIA) process described below.
Responsiveness to social determinants policy and planning efforts
EHB also began engaging in a wide range of social determinants policy and planning efforts. For example, the Director analyzed a proposed living wage ordinance and presented the findings to the Board of Supervisors, who considered in in their policy discussions and eventual passage of the ordinance. Community advocates took note of the Department’s willingness to testify to the health impacts of the policy, and developed a relationship with EHB staff that led to partnerships on many other issues. In another example, community organizers working in several San Francisco neighborhoods were concerned about gentrification, displacement, housing availability and affordability, and environmental quality and demanded accountability from city government. Recognizing that environmental justice and displacement were social determinants of health, EHB began to explore how to support meaningful community engagement to address these inequities.
In 2002, the Director established the Program on Health, Equity and Sustainability (PHES) “to work in partnership with residents, public agencies, and private organizations to advance healthy environments and social justice.” Initially, PHES staff included the 2 new epidemiologists funded from EHB revenues and several consultants and interns hired through hazardous waste fines, which were managed by a third-party nonprofit fiscal agent. Over time, PHES applied for and received various local, state, and federal grants to expand their staff capacity and work.
Developing a mission statement
In 2004, guided by the Ottawa Charter for Health Promotion, the PHES team developed their mission and statement of purpose:
“The Program on Health, Equity and Sustainability supports San Franciscans working together to advance urban health and social and environmental justice. Through ongoing integration of local government and community efforts and through valuing the needs, experiences, and knowledge of diverse San Francisco residents, we accomplish this by:
- Initiating and facilitating dialogue and collaboration among public agencies and community organizations;
- Expanding public understanding of the relationships between the natural, built, and social environments and human health;
- Supporting local capacity for participation in public policy;
- Conducting and supporting local and regional research;
- Developing and evaluating new methods for interdisciplinary and inclusive involvement in public policy;
- Documenting and disseminating our strategies.
In our vision of San Francisco, communities are engaged in democracy and committed to equality and diversity. We believe this will create and maintain sustainable and healthy places for all San Franciscans to live, work, learn, and play.”
Staff hired with commitment to social justice and equity and key skills
Starting with the first 2 epidemiologists hired in the early 2000s, PHES sought to hire people with a deep commitment to social justice and equity, as well as skills and experience to advance social determinants of health work. Over time, as PHES evolved, this has meant hiring people with experience in social epidemiology, community-based participatory research and popular education, ArcGIS and mapping, database development and management, policy analysis, and urban planning.
PHES sought to proactively engage community and government, inform policy
PHES sought to proactively engage community members and other government agencies to discuss key issues facing San Franciscans. This was motivated by the following: 1) one of the chief complaints among environmental justice and anti-displacement advocates was that the government was not paying attention to the needs of low-income communities of color; 2) meaningful community engagement can improve health, relationships, and policy; and 3) health data supported the community’s complaints about disproportionate impacts but was not being considered by decision makers.
This engagement occurred in several ways:
- Creating and/or participating in task forces and advisory bodies
- Conducting Health Impact Assessments and health analyses of public policy
- Developing tools to analyze potential health impacts of policies, projects, and plans
- Organizing health equity training, education, and collaboration opportunities
- Leveraging regulatory authority to support health equity
Each of these strategies is described briefly below. For more detailed descriptions of PHES’s initial work, see Using Our Voice: Forging a Public Health Practice for Social Justice in Tackling Health Inequities Through Public Health Practice: Theory to Action and/or visit the PHES website.
Creating and/or participating in task forces and advisory bodies
Throughout the past 15 years, task forces and advisory bodies have been a key PHES strategy for advancing health equity. Three notable examples include the creation of the Asthma Task Force to address the asthma epidemic; the Food Security Task Force to address hunger and food insecurity; and the Pedestrian Safety Task Force to reduce pedestrian injuries and neighborhood injury inequities. All 3 task forces (and various others listed below) were formed in response to health data reports documenting preventable inequities; co-chaired by PHES staff or EHB staff affiliated with PHES; and focused on improving data collection and using the data to inform better public policy, usually with an emphasis on improving the social determinants of health.
The task force/advisory group model facilitated relationship building between PHES staff, government agencies, and community-based organizations to take on additional work outside of the formal bodies. The task forces also became a key way for other agencies to understand the added value of health and equity in policy discussions.
Conducting Health Impact Assessments and health analyses
In 2004, PHES convened a diverse Community Council of over 20 organizations and public agencies to conduct the Eastern Neighborhoods Community Health Impact Assessment (ENCHIA). Formed in response to the anti-displacement concerns of lower-income communities in the city’s eastern neighborhoods, ENCHIA envisioned a healthy San Francisco for all and identified policies and programs to achieve that vision. One of the first community-based Health Impact Assessments (HIAs) in the US, ENCHIA became a nationally recognized model for meaningful community engagement in land use planning processes.
One of the main products of ENCHIA was the Healthy Development Measurement Tool (HDMT), which provided a methodology to evaluate land use policies, plans, and projects. HDMT, now called the SF Indicator Project, is an online framework and data repository that examines how San Francisco neighborhoods perform across multiple dimensions of a healthy, equitable community. The SF Indicator Project has been used in baseline conditions assessments and evaluations of long-range planning efforts in San Francisco. Community groups, academics, and journalists have also utilized the tool for advocacy, research, and communication. It has been widely used and adapted across the US.
Building off the living wage analysis described above, advocates also requested that SFDPH conduct HIAs of proposed state and federal paid sick days legislation; findings were subsequently used in public testimony and advocacy to advance paid sick days. PHES staff also conducted health analyses on transportation, housing, parks, employment, and food-related policies.
Health Impact Assessments Facilitate Engagement
In many cases, the HIAs and health analyses facilitated deeper engagement with government agencies responsible for the issues being assessed, and with community advocates who had a related policy agenda.
Developing tools to analyze potential health impacts of policies, projects, and plans
To strengthen their work and better improve the consideration of health in decision making, PHES developed a set of tools to quantitatively or qualitatively predict the impacts of proposed policies, projects, or plans on health. Each of these was piloted in San Francisco and used to inform decision-making processes. Several have received national recognition and/or have been adapted to other localities. These tools include:
- HDMT/SF Indicator Project
- Air Quality and Noise Measurement Exposure Models
- Community Resilience Index and Heat Vulnerability Index
- Pedestrian and Bicycle Environmental Quality Indexes
- Vehicle-Pedestrian Injury Collision Model
- Pedestrian Flow Model and People Count
Organizing health equity training, education, and collaboration opportunities
PHES received many requests from other health departments, academics, community groups, and government agencies to share tools and experiences and provide technical assistance. PHES organized trainings on the HDMT/SF Indicator Project, predictive modeling tools, and HIAs and delivered them to local and national audiences.
Leveraging regulatory authority to support health equity
As described in the Wage Theft case study, another PHES strategy to increase equity in decision making was to leverage EHB’s regulatory authority to promote more equitable living and working conditions for San Franciscans. An early example of this was Trinity Plaza, where developers proposed demolishing affordable rental housing to build market-rate housing in central San Francisco. Staff used the existing California Environmental Quality Act (CEQA) — which had traditionally not been used to measure and mitigate displacement impacts on health in the environmental review process — to address the direct and indirect impacts of demolishing Trinity Plaza. Staff conducted focus groups with Trinity Plaza residents who were at risk of eviction and submitted a report as evidence of inadequate compliance with CEQA. Along with community organizing around the project, this work resulted in the developers’ committing to provide affordable housing units for every unit lost to the new development.
Outcomes and Impacts
Throughout the past 15 years, PHES has had numerous successes in meaningfully engaging community members and government agencies to address health inequities in San Francisco. As a result of their collective research and collaboration activities, many concrete administrative and legislative policy changes have been made and/or implemented. More broadly, the scope and responsibility of the Department has significantly shifted. Positive outcomes include:
Reframing the narrative and role of EHB
By engaging directly with and responding to the needs of a wide range of government agencies and community partners, PHES — and, more broadly, EHB — was able to demonstrate its value to partners and change the narrative of what a health department could do. Participating in task forces, conducting health analyses, developing quantitative research tools, and proactively engaging in policy debates showed that PHES had a will to act and would use its resources to advance mutually beneficial goals. All of this also led to changing expectations of the Department and contributed to building deeper and more longstanding relationships with government and community partners. As EHB was one of the first health departments in the country working directly on housing, land use, and transportation issues, PHES’s work provided the field of public health more broadly with concrete examples of how to support social justice movements and work on the social determinants of health.
Creating a culture of innovation and staff empowerment
By providing opportunities for staff autonomy and innovation, EHB expanded how a very wide set of public health practitioners — from inspectors to epidemiologists — saw themselves and their role in advancing health equity and improving living and working conditions. Not only did this not bring direct resources and staff time to work on health equity issues, but it also created a culture where staff are viewed as active agents in making change within the Health Department and the broader community.
Concrete policy change to advance health
PHES’s policy and systems change work led to concrete changes in housing, land use, transportation, labor, parks, and food systems policies that have improved living, working, and community conditions for thousands of San Franciscans. SFDPH Policy Milestones 1999–2011 (PDF) provides an overview of the administrative and legislative policy outcomes resulting from PHES’s research and collaboration efforts between 1999 and 2011. Profiles of Health and Planning (PDF) provides brief descriptions of how PHES helped integrate public health into urban planning and economic development. Additional information about many of these projects is available on the PHES website.
Since its creation, PHES staff size has fluctuated depending upon the availability of grants and other funding to sustain the work. As of 2017, PHES includes 5 staff in the Environmental Health Branch; however, the tools and experience of PHES have impacted many other areas of the health department. Following a 2014 Health Department restructuring, some epidemiologists and program planners who were originally housed in PHES are now located in the Office of Policy and Planning, the new Community Health Assessment Unit, and the new Office of Equity and Quality Improvement.
Today, PHES’s work is more institutionalized and technically focused than it was initially. SFDPH will continue to coordinate the SF Indicator Project, the Vision Zero task force, TransBASEsf, and other projects that involve government agencies and community partners to advance health in policy contexts. PHES staff will continue to sit at decision-making tables with planning, transportation, housing, education, and other agencies as part of their Health in All Policies approach.
Advice for Local Health Departments
Support an authentic community agenda
To address equity, it’s important to understand what people are struggling with and fighting for in their communities and how that aligns with your goals of advancing health equity. Your work should be guided by the community’s agenda and be transparent and accountable to them. At the same time, be clear about what you can and cannot do as a health department. Provide concrete examples of things the health department could do to support or inform the community’s agenda — e.g., gathering data, conducting focus groups or surveys to elevate community voices, testifying on health impacts, convening various stakeholders and government agencies, etc.
Request letters for public servant action
It can be helpful to have clear requests for health department involvement from community organizations or other collaborators. As public servants, the health department is responsible for responding to these public requests. This also helps justify the work if there is a change in leadership or resources. If something is hard for you to do politically, tell community organizations to make the request directly to the Director of your agency or to elected officials who can direct your agency to respond.
Know and use your legal authority
PHES sometimes leverages their existing legal authority to ensure accountability to health. For example, in the Trinity Plaza redevelopment, they highlighted that displacement is a health impact under existing state law, and forced the city to acknowledge they were potentially going to violate the law by not addressing the displacement impacts. PHES’s role did not demand additional budgetary resources, but it did require them to know and use their legal authority. Another example is their work in leveraging health permits [link to other case study] to address wage theft. Don’t be afraid to use and/or name your statutory authority as a justification to do social determinants work.
Work with and be responsive to critics
Doing social change work means disrupting the status quo, so it’s important to expect opposition from above and below. Some people may feel threatened when their scope of work is being changed or when you are doing work outside of your traditional role. Be clear about what’s guiding your work, especially in discussions with people who are critical. It is important to confront these criticisms head on in a transparent and honest manner.