Building on the results of health assessments and a revised strategic plan, the Santa Clara County Public Health Department, California, is developing internal infrastructure to advance racial and health equity. This includes hiring dedicated staff to lead department-wide efforts, developing a training program for its public health workforce, and pilot testing the application of racial equity tools.
Who Took This On
Santa Clara County Public Health Department, California
Ways You Can Get Started
- Include racial and health equity language in organizational strategic plans, mission and vision statements, and goals and objectives
- Explore participating in the Government Alliance on Race and Equity
See Advice for Local Health Departments below for more ways to take action.
What Sparked This?
Strategic planning and department reorganization help prioritize health and racial equity efforts
Located in the southern San Francisco Bay Area, Santa Clara is home to many start-up and global technology companies and is one of the wealthiest counties in California. While Santa Clara’s 15 cities appear to be healthy and wealthy, many communities experience significant disadvantage.
In 2014, the Santa Clara County Public Health Department (SCCPHD) began revising their strategic plan, in part as a requirement for public health accreditation. At that time, the Department had a longstanding commitment to health equity and a strong reputation for Community Health Assessments that link the social determinants and poor health across subpopulations, including people of African/African ancestry, Latinx, Vietnamese, children, and LGTBQ communities. Yet SCCPHD grappled with how to better operationalize their health equity work, and whether they should lead with race by explicitly naming the communities most impacted by racial inequities.
An SCCPHD team with deep commitment to social and racial justice, quality improvement, and strong qualitative and quantitative methods facilitated the strategic planning process to develop a set of priorities. After leadership approved the priorities, workgroups defined goals and objectives for each priority, and the strategic plan was finalized in late 2015.
The strategic plan included a new Department priority — “Advancing racial and health equity to eliminate health disparities” — which would be accomplished by the following goals:
- Prevent violence and its negative health impacts
- Strengthen Department programs, services, and policies to address racial and health equity
- Build county capacity and community awareness to mitigate and address climate change health effects
Over the summer and fall of 2015, SCCPHD underwent a reorganization to support the new strategic plan. The County Health Officer became the new Director of Public Health, and leadership established a new Office of the Director where racial and health equity work was housed. Critical to establishing the infrastructure to support the racial and health equity work was the request and allocation of resources to hire a Senior Health Program Manager by the County Board of Supervisors.
In 2017, the County Board of Supervisors also approved funding for 3 additional racial and health equity staff to implement recommendations from the 2016 Children’s Health Assessment. These recommendations focused on addressing the structural and institutional racism, discrimination, harassment, and biases across systems that contribute to inequitable outcomes for children and families.
Leadership participates in Government Alliance on Race and Equity
SCCPHD applied to participate in a year-long training cohort sponsored by the Government Alliance on Race and Equity (GARE) in order to strengthen and advance their racial and health equity work. The SCCPHD GARE team was comprised of the Health Officer/Public Health Director, Deputy Director, Executive Director, 3 mid-level managers, staff from 3 SCCPHD departments, and a representative from the county-level Office of Cultural Competency. The first cohort began its GARE journey in January 2016 and “they haven’t looked back since.” SCCPHD also signed up to participate in the second GARE 2017 cohort, inviting staff from the Offices of Social Services, Behavioral Health, Probation, and Cultural Competency to join the team.
“As a result of our participation in GARE, we have a robust workplan with a clear theory of change of how we will normalize conversations about racial inequities, organize our workforce, and operationalize our department’s racial equity work.”
Dedicated senior manager coordinates racial and health equity work
The SCCPHD Racial and Health Equity Senior Health Care Program Manager is the primary staff person leading and coordinating the Department’s racial and health equity work. She is responsible for managing workplan implementation and establishing the Department’s infrastructure to develop common language and tools. The Senior Manager is intentional and inclusive, and aims to motivate, organize, and mobilize staff participation in the Department’s racial and health equity work. Working through a committee structure, she convenes, facilitates, and manages the behind-the-scenes processes necessary to drive implementation. For example, she does all the prep and follow up for the workgroups so that “in the hour and a half that someone participates, he or she can be a strategic thinker and active participant, but not have to do a lot of additional work outside.” She only calls in-person meetings on an ad-hoc basis for decision making and strategic guidance, and instead uses email to gather input on materials and processes and provide status updates.
Department staff participate in racial and health equity committee and workgroups
SCCPHD developed a cross-department racial and health equity steering committee to expand understanding of and application of principles and practices to achieve racial and health equity. The committee ensures that training, communication, and other necessary resources are available to employees to establish a uniform understanding of and commitment to equity. The committee is comprised of 25 SCCPHD staff including nurses, a workforce development coordinator, a communication specialist, community health workers, program managers, a nutritionist, an epidemiologist, deputy health officers, and 3 executive directors.
There are multiple staff engagement opportunities in which leadership actively encourage staff to participate. As described below, a training workgroup developed a racial and health equity training plan and curriculum to provide introductory training to all public health employees. And SCCPHD is in the process of convening a workforce equity team to create a workplace culture where racial equity is valued and operationalized. They will conduct an analysis of racial representation across the Department’s workforce, with the goal of establishing a pipeline program to diversify the workforce.
Operationalizing racial and health equity workplan
As a result of SCCPHD participation in GARE, the Department completed an organizational assessment that informed the development of a robust racial and health equity workplan. It outlined strategies to normalize conversations about race, organize the Department to achieve racial equity, and operationalize new policies, programs, and budgetary decisions using a racial equity lens.
The department adapted GARE’s Racial Equity Toolkit into a Budget Equity Assessment Tool and then piloted this tool for the FY 2018 budget process. Its application provided important information to prioritize Department budget proposals. The Department is also exploring the use of racial equity tools in program and policy development, and including health equity in their quality improvement work to support public health accreditation.
Developing all staff trainings on equity
One of SCCPHD’s first tasks was to develop an introductory training for all 460 staff on core equity topics. SCCPHD staff identified equity champions in their workforce and recruited them to participate as trainers, using a train-the-trainer model to build internal capacity and expertise.
The SCCPHD Racial and Health Equity Learning Institute was designed to provide staff with a shared understanding, language, and framework to advance racial and health equity within government systems. The in-person training consists of 6 workshops, ranging from 1.5 to 4 hours each. The workshops are a mix of didactic content, interactive exercises, and videos around the following topics: 1) Introduction to Racial and Health Equity, 2) Structural Racism 101, 3) LGBTQ Health, 4) Climate Change, 5) Cultural Humility and Competency, and 6) Community Engagement.
The trainings aim to develop a shared understanding of equity among staff, and provide a safe and inclusive space to discuss the legacy of discrimination, implicit bias, and structural racism in their work and in their lives. The goal is to build a movement and identify change agents to transform how the organization approaches its work.
Engaging community partners wherever possible
In addition to focusing on getting their “internal house in order,” whenever there is an opportunity to invite the community to participate in Department processes or trainings, SCCPHD invites community members to share their experiences, perspectives, and recommendations. Moving forward, the Department will work with community partners to share the work that is being done internally, and will work with community organizations to further develop trainings. SCCPHD is figuring out how to fairly compensate community members for their time and participation.
Outcomes and Impacts
Calling out structural racism
The Department is more willing to explicitly name structural racism and discrimination as factors impacting health. Although racial profiling, fear of police officers, lack of trust with the local African ancestry community, and structural racism have come up in prior health assessment focus groups and surveys, the Health Department is more explicitly calling out these factors, particularly structural racism, in their reports and communications. As noted by the Senior Manager, “We’ve learned we have to be intentional, explicit, and avoid using proxy terms. We name things what they are and call them out. We use what the community said in their words. And we are explicit that the systems we have are not serving certain families and community areas.”
Learning to be humble and accountable to community
Through the African Ancestry Assessment in particular, and other assessments more broadly, SCCPHD staff better see the power of the community to which they are responsible, and have learned when to step back and listen. By listening to community concerns and priorities, they have developed mutually beneficial relationships and discovered that the process can be more important than the outcomes when it comes to advancing equity.
Interest in racial equity at hospitals and across the county
As others learn about SCCPHD’s work, the Senior Manager is more frequently invited to meetings with hospital and other county leaders to learn more and understand opportunities for potential collaboration around racial and health equity.
Increased funding and political support from county
SCCPHD has seen a shift in the Board of Supervisors, who are not just funding the health assessments but also more actively funding implementation and community engagement to follow up on the assessments. The County Supervisors recently approved 3 staff positions for fiscal year 2018. SCCPHD will hire a trainer, data and policy analyst, and planner to support, broaden, and deepen their work.
Advice for Local Health Departments
It’s OK to go slow and to “slow up”
Working on equity is a long-term project. It took SCCPHD a long time to achieve what they have achieved, and the next steps will also be slow. Break down the work into smaller pieces, understand how to approach the work with limited resources and staffing, and go at your own pace so you don’t burn out. Don’t compare your pace to others’. In 2016, there was an effort in SCCPHD to finish all their trainings by the end of the year. In the middle of that, they realized they needed to “slow up.” Santa Clara County is different than other counties, and that’s what defines it. By going at their own pace, SCCPHD ensures everyone is moving together, rather than some moving forward without buy-in and agreement from others.
Ensure continuous communication and accountability
Although you can go at your own pace, you also need to make sure you are moving forward and accountable to your plans. Creating systems of continuous communication makes it easier for new people to get involved in the process and promotes transparency, and having clear short-term goals can help you stay motivated for the longer-term work. In SCCPHD, communication has been instrumental for getting people on board with racial and health equity work. Meeting programs where they are has been a critical organizing strategy for the Department to shape and drive the narrative for their work and to build momentum.
Normalize being uncomfortable and not knowing what to do
In public health there is a tendency to over-process things before putting them into practice. Learn to be OK with things not being perfect, testing them out, and learning from the experience. Always assume that things are being done with the best of intentions, and be flexible enough to adapt to changing political contexts and leadership.
It is helpful to apply community organizing principles to working within a government — in other words, become an activist in your own bureaucracy. Organizing from within means organizing your colleagues and workforce. It is going to take time, but key principles to use include: meeting people where they are, understanding what motivates them, helping them understand why you are doing this work, trying to be non-threatening, and moving slowly but continuously.
Support healthy minds and bodies
When doing this work, self-care is important but often ignored. SCCPHD is exploring developing healing circles and thinking proactively about how to take care of the heart and mind of trainers and participants.
It is important to have leadership at the table
SCCPHD executive management has been directly engaged and visible in the Department’s racial and health equity efforts. This involvement not only has signaled commitment to this priority, but also sets the stage for broad and deep involvement within the Department.