Paths to health equity: Insights from Detroit, Tampa, St. Louis, Montgomery County, Shelby County, and Guilford County

Executive summary

Program introduction

The Earning Trust to Build Equitable and Healthy Societies (ET4HS) program helped local governments develop innovative approaches to address health disparities.

As part of this program, participating cities and counties joined an international network dedicated to learning and sourcing solutions for health equity issues. By connecting with global institutions, international public health officials, and grassroots health equity organisers, participants learned about proven international approaches that they can tailor to their local context to address complex health challenges. In addition to promoting a Culture of Health, the program sowed relationships between government and community to help restore trust and legitimacy, thereby laying the groundwork for more effective governance moving forward.

This report was authored by Elysse Alvarado, Felix Ferrandis, Giselle Cordero, Nicole Hildreth, and Valerie Odonkor.

Program overview

ET4HS helped local governments address disparities within the community to support health and well-being for all, advancing health equity through a combination of trust-building activities, community cocreation, and the adaption of proven international approaches. 

During the program, participating teams received access to resources and tools that can positively impact their communities' health outcomes. These included cross-city workshops on power and building legitimacy, skill-based community engagement exercises, and a combination of individual and group support. The program also connected participants to other local governments focused on similar health equity challenges and international public health experts who share proven approaches that may be adaptable to local contexts.

What is earned legitimacy, and why ET4HS?

CPI believes that a government is arguably only legitimate if it has the support of the people it purports to serve, and that support is invariably tied to the amount of trust the people feel for their government. Earned legitimacy refers to the admission that the government must work tirelessly with the people it serves to increase community trust, continuously demonstrate its value in people’s lives, and maintain the very promise of democracy. 

ET4HS rests on the premise that complex social factors and ingrained systemic barriers have a powerful impact on individual, family, and community health outcomes. So powerful, in fact, that people in some communities will die 20 years earlier than others living just a few miles away. To reduce these stark disparities, local governments must both address inequities in the social determinants of health, including education, wealth, care, community, and environment and restore the damaged trust with the individuals that are closest to those issues.

The 2023 ET4HS cohort

In the 2023 ET4HS cohort, six local governments joined with community partners to address issues ranging from inequities faced by the disability community to lead contamination and building trust for greater collaboration. Selected cities and counties include Detroit, MI; Guilford County, NC; Montgomery County, MD; Shelby County, TN; St. Louis, MO; and Tampa, FL.

ET4HS connected these U.S. governments to a global network advancing solutions for health equity. Our 2023 international partners include Butuan, Philippines; Latrobe Valley Health Assembly, Australia; Latrobe Valley Health Advocate, Australia; La Fábrica de Renca, Chile;  Lusaka, Zambia and Umuaka, Nigeria.

Our methodology and approach

During the ET4HS program, government participants developed skills to better work with communities and then created a plan to tackle a specific local health equity issue. By the end of the program, participants had:

• Presented a program capstone to senior local government leadership and community members; 

• Gained expertise in applying a toolkit of exercises that build community/government trust and encourage codesigned innovation; 

• Interacted with government and public health officials from around the world to learn best practices for building legitimacy and equity;

• Built proficiency in core equity skills; 

• Developed a plan of action to apply core equity skills to address other community challenges; and 

• Gained membership into the Centre for Public Impact (CPI) Legitimacy network. 

Key takeaways for local governments seeking to advance health equity 

Advancing health equity and promoting a Culture of Health locally is a complex challenge that can seem like an uphill battle. However, a few key lessons emerged over the course of the ET4HS program. Some of these lessons were directly derived from best practices shared by experts from other countries. They may be helpful for local governments at large to start addressing multifaceted health issues. Below are five lessons from ET4HS that we believe are applicable to other governments seeking to tackle health disparities. Across all of these recommendations, governments must factor in their community contexts and adapt accordingly.

1. Be open to adapting strategies to foster trust and understanding.

Government leaders seeking to advance health equity must prioritise adapting strategies that foster community trust and understanding. This entails more than just acknowledging the needs of residents; it requires actively engaging with the community on a personal level. By embracing a human-centred approach, local governments can establish authentic connections through meaningful dialogue. 

Latrobe Health Advocate Jane Anderson took a unique approach to community engagement in Latrobe Valley, a regional town in Australia. Whether travelling on local buses or spending time at bus terminals, she actively engaged with community members. This approach proved highly effective in building trust and fostering connections with the local population. Dr C’fine Okorochukwu and Lesley Agams implemented trauma-informed practices as taught in Nigeria, demonstrating a genuine commitment to meeting the diverse needs of all individuals and building trust within the community. 

Recognising innovative approaches is critical to addressing complex and deep-rooted disparities that persist - as traditional methods often fall short in achieving equitable outcomes - and is fundamental to breaking down systemic barriers. By actively listening, learning, and empathising with the lived experiences of community residents, local governments can demonstrate their commitment to developing more responsive policies that will lead to lasting improvements to provide everyone with a fair opportunity to thrive. 

2. Encourage inclusive engagement to empower communities.

By purposefully and intentionally involving community members in the decision-making process, local governments, both here in the U.S. and abroad, can unlock effective solutions to complex health challenges. 

During a session dedicated to how to equitably engage community members as learning partners, participants had the opportunity to learn first-hand from Javier Morales, the Executive Director of La Fábrica de Renca, Chile, who emphasised the need to weave community input into every development stage of new initiatives using methods like town halls, workshops, surveys, or interviews. 

Policymakers must listen and embrace the expertise and lived perspective of those most affected by health disparities to design programs that address the root causes and meet the community's needs. As emulated in ET4HS during cocreation workshops, this collaborative approach fosters a sense of ownership and investment among residents while leading to sustainable outcomes. Government leaders can establish stronger partnerships and empower communities to drive meaningful change by honouring and recognising the community's invaluable knowledge. Advancing health equity will require leaders to develop and tailor inclusive engagement practices, prioritise authentic connections, and create avenues for meaningful, transparent collaboration. 

3. Build collaborative partnerships to advance health equity.

Recognising that health equity is a multifaceted challenge, it is evident that partnerships play a pivotal role in developing a comprehensive response. By leveraging collaborative relationships and networks, local governments can access a wide range of expertise and resources essential to address the root causes of health disparities. Partnerships serve as a powerful mechanism for gathering diverse knowledge and insights.

Within the ET4HS program, the experience of the Shelby County team exemplifies the transformative potential of collaborative partnerships. Led by a community partner rather than a government entity, as typical in CPI’s programming, the Shelby team was able to utilise an existing cross-sector collaboration to tap into a broader network of governmental agencies and other stakeholders for a holistic approach to their health equity issue.

This approach is further exemplified by the collaboration of the Latrobe Health Assembly and Latrobe Health Advocate, both international participants in the program, which work and communicate daily to create a lasting impact in their community in Australia. If governments embrace more collaborative approaches, they can not only foster trust and legitimacy within the community but also establish a robust platform that enables collective action, innovation, and sustainable change. Forging collaborative partnerships acts as a catalyst for advancing health equity.

4. Utilise data to inform decisions to maximise impact and accountability.

Throughout the ET4HS program, the importance of data became evident as participating teams grappled with its availability and relevance. While many encountered gaps and limitations in existing data sets, their presence played a crucial role in substantiating the reality and urgency of health disparities.

While access to care still often remains the focal point of creating a Culture of Health locally, health equity encompasses a broad spectrum of social determinants. Data empowers local governments to explore the varied factors contributing to health disparities, including housing, education, employment, wealth, and climate. Pierre Anthony Joven from the Butuan City Agriculture Office in the Philippines articulated how his team used a human-centred approach to data collection, through surveys and behavioural observations, to determine the likely most effective way to address underinvestment and food insecurity in his community.

By harnessing data, governments gain insights into the underlying drivers of inequities, enabling them to craft targeted interventions and appropriately allocate resources to address the root causes. However, there needs to be a concerted effort to sustain data collection and reporting systems to capture the nuanced realities of health equity. Through robust data analysis, local governments can maximise the impact of initiatives and foster further accountability.

5. Lean into sharing power for equitable decision-making.

International participants and subject matter experts located all over the world – from Australia, Chile, Nigeria, Philippines, and Zambia – highlighted the need for redistributing power to drive equitable decision-making and advance health equity. Their contributions highlighted that local governments must engage in a paradigm shift to actively involve communities in decision-making processes and acknowledge their expertise and lived experiences.

One such example came from Ellen-Jane Browne and Tanya Rong from the Latrobe Health Assembly, who noted they hold co-design workshops where the community plays an active role in shaping health initiatives. This collaborative approach ensures policies and programs are better suited to the needs and values of those they serve, ultimately leading to more equitable outcomes. Pairing these efforts with a change in narrative is essential in building community confidence and trust in the government’s commitment to equitable outcomes.

By actively demonstrating the government's dedication to inclusive governance and providing the community with transparent updates on progress, the definition of success can slowly shift and transform to enable communities to see the tangible improvements resulting from their involvement.

Barriers to keep in mind 

When addressing a complex issue like health equity, challenges are inevitable. Based on our experience in ET4HS, the following pain points are likely in any effort. By recognising the significance of these challenges and actively working towards overcoming them, we can build a more equitable healthcare system that meets populations’ diverse needs. The following challenges highlight the importance of community accountability, improved communication and collaboration, emphasising social determinants of health, ongoing iterative work, and breaking down silos:

1. Community accountability: local governments must prioritise community accountability as a fundamental principle. To establish trust, the government must demonstrate a comprehensive understanding of the intricacies that exist within government structures and take proactive steps to bridge any gaps in access and knowledge. It is essential for residents to have the ability to engage with their government leaders, while expecting tangible actions and outcomes. Furthermore, residents should understand the relevant agencies to approach for necessary services and additional support. This two-way interaction between the community and the government fosters transparency, responsiveness, and a sense of shared responsibility in addressing the diverse needs and concerns of the community.

2. Improved communication and collaboration: effective communication, including language access and consistent information dissemination, is necessary to reach diverse populations. While this held true across program participants and partners, the city of Lusaka provides a particularly powerful example. Lusaka worked to cocreate community solutions and utilised imagery to communicate and brainstorm ideas. The need for strong communication and collaboration also exists within the government itself. Oftentimes siloed government operations hinder the exchange of vital information and impede the progress toward shared goals. Fostering cross-departmental collaboration will support and drive the work forward. 

3. Emphasising social determinants of health: addressing health disparities requires acknowledging that they are deeply intertwined with broader societal issues. Local governments must understand the impact of social determinants of health and take a comprehensive approach to address underlying determinants. A healthier and more equitable society can be created by addressing systemic factors such as education, employment, housing, and resource access. Tackling the root causes rather than merely addressing individual health problems is crucial for sustainable progress.

4. Ongoing iterative work: both health equity and earned legitimacy require an ongoing commitment. Local governments must shift from a finite to an infinite mindset, recognising that sustained progress necessitates adaptability and a readiness to reassess and redefine strategies when needed. This iterative approach ensures that governments remain proactive and responsive to the evolving needs of their communities.

5. Breaking down silos: Health equity efforts, both at local and broader levels, often suffer from being siloed and lacking cohesion. This fragmentation poses a significant challenge as local solutions may not adequately address systemic and underlying root causes of health disparities. It is essential to create opportunities for changemakers to connect, collaborate, and exchange ideas; cross-sectoral collaboration is crucial to promote cohesion. By sharing insights regularly, collective efforts can address multifaceted aspects of health equity more comprehensively.

Deep dive: the 2023 ET4HS cohort 

The 2023 cohort of ET4HS welcomed participants from six cities, encompassing a range of diverse backgrounds and job roles. This diverse representation ensured a rich exchange of perspectives and experiences, enhancing the program's ability to effectively address complex health equity challenges. 

Demographics 

Moreover, the core teams actively collaborated with community members in cocreation sessions, generating a significant number of ideas to tackle these challenges. The inclusive process involved 46 cohort members, consisting of government and community leaders from three cities and three counties, who actively engaged with more than 80 community members in Community listening sessions (CLS) and Cocreation sessions. This emphasis on diversity and community representation ensured that the program's strategies and initiatives were informed by a wide range of voices, experiences, and expertise, fostering a more comprehensive and inclusive approach to advancing health equity.

Throughout the program, ET4HS gathered both quantitative and qualitative data to assess its impact. Data collection methods included Zoom polls, a baseline survey, and an end-of-program survey, which evaluated the participants' comfort with essential skills. Qualitative data consisted of the participants' reflections, experiences, and feedback. 

• Government teams: 6

• Public servants: 21

• Residents engaged by work: 93

• 100% respondents learned new skills about how to build stronger relationships with communities

• 92.3% of respondents are applying the skills earned in the program to day-to-day work

• 100% of respondents would recommend working with CPI to a peer

Cities and counties in the 2023 ET4HS program used knowledge from cross-city workshops on power and building legitimacy and skill-based community engagement exercises to develop solutions to the following health equity questions:

• Detroit, Michigan: How can the Detroit government improve access to mental health services for the disability community and their support system?

• Guilford County, North Carolina: In a post-pandemic context, what systems can Guilford County government establish to involve the community in defining 'Access to Care' and shaping policies to reduce local disparities?

• Montgomery County, Maryland: How can Montgomery County Health and Human Services enhance programs and assess their impact on addressing youth needs in high-violence areas while promoting equitable community engagement?

• Shelby County, Tennessee: How can Shelby County collectively increase knowledge about lead contamination and service systems countywide, and overcome barriers to disseminating information and providing resources?

• St. Louis, Missouri: How can the city effectively engage and motivate both the government and communities to support and implement a health equity plan while strengthening health services?

• Tampa, Florida: What opportunities can Tampa offer to address youth unemployment and improve access to quality healthcare for young individuals and their families?

In the following case studies, we will explore the details of each participant's approach to advance solutions to their health equity question.

St. Louis has a long history of racial segregation and discrimination. In the early 20th century, the city implemented racially restrictive housing covenants and redlining practices, systematically excluding African Americans from certain neighbourhoods and denying them access to loans and mortgages. This created racially segregated communities with limited resources and opportunities for African-American residents. 

Over time, these systemic inequalities have profoundly impacted the health and well-being of Black residents in St. Louis. Statistics reveal alarming disparities, such as Black babies being three times more likely to die compared to white babies and a 20-year difference in life expectancy between Black and white St. Louisans. Environmental and health inequities further compound the challenges faced by marginalised communities, with Black children being disproportionately affected by lead poisoning. 

In terms of healthcare access, Black residents in St. Louis are twice as likely to be uninsured and have limited availability of primary care providers in predominantly Black neighbourhoods. This lack of access to quality healthcare exacerbates health disparities and contributes to poorer health outcomes among Black populations.

In response to this complex history intertwined with racial inequities and significant events like the tragic death of Michael Brown in 2014, the City of St. Louis Health Department recognised the urgency of developing a comprehensive health equity plan.

The primary obstacle in implementing and carrying out the health equity plan is the deep-rooted lack of trust in the government within the community. This mistrust stems from a history of disinvestment and recent instances of government corruption. Community leaders, residents, and government employees feel that there has been a lot of talk but minimal action. Furthermore, there is a pressing need to enhance collaboration between the city, partners, and residents to effectively support the health equity plan on a broader scale. 

To address this challenge, the St. Louis Department of Health actively engaged with community members, leaders, and employees during the ET4HS program to research and explore solutions that can foster improved implementation and support for the plan. Several pivotal conversations from community listening sessions provided invaluable clarity on how citizens perceive abstract equity-related topics and the role of the Department of Health in the community. 

Recurring themes that emerged from conversations with employees, partner organisations, and community members revealed the following:

1. The Department of Health needs more visibility and esteem among communities of focus. While programs are implemented, there is a lack of sustainability planning. Furthermore, insufficient communication and connection with the individuals served by the health department result in residents being unaware of the positive impacts of the offered programs.

2. The department lacks a comprehensive understanding of community expectations regarding services aimed at addressing health inequities. There is a need for a shared definition of health equity among stakeholders, highlighting the importance of involving communities in co-developing this definition.

3. Trust in government, particularly regarding equity initiatives, is low. Participants expressed scepticism, viewing equity as a term that perpetuates favouritism towards specific neighbourhoods. People perceive equity as a byproduct of capitalism, where some benefit at the expense of others. Long-term residents feel neglected and express that little has been done for their well-being since the city's inception.

Building upon the wealth of knowledge gained from international subject matter experts such as Latrobe Valley Health Assembly and Health Advocate varying approaches to community engagement and cocreation, the St. Louis team developed a series of recommendations to city leaders for a health equity plan roll-out, which will lay the foundation for increasing community trust in government as well building a more equitable St. Louis. These include:

1. Enhance community outreach by increasing involvement in community events and developing outreach materials to create an effective definition of “health equity” moving forward. 

2. Increase department visibility within the community through partnerships with shared organisations, create accessible spaces for community input, and foster relationships with city leadership.

3. Implement internal capacity building by beginning quarterly training on health equity with employees. Training will be tailored to specific bureaus in order to show that equity is ingrained in day-to-day work.

The St. Louis core team is currently in a position to translate their insights into tangible action. They developed an action plan that is expected to be finalised by the end of the year. 

• Develop health equity education materials in partnership with a designated advisory group that will guide language and design by July 31, 2023.

• Launch and complete a mobile listening tour to encourage bilateral listening between their office and the alderpersons, an initiative born of their community listening sessions, by August 31, 2023.

• Host a town hall meeting to address the pending health equity plan and to encourage trust between the Department of Health and the community by November 30, 2023.

• Partner with the Regional Health Commission to develop culturally competent health equity training materials for all staff by January 1, 2024.
  

Montgomery County, Maryland, is renowned for its affluent communities, exceptional education system, and diverse population. However, the county faces numerous challenges, including affordable housing, economic disparities, limited healthcare access, and the need to promote racial and social equity. Additionally, a growing concern about youth violence stems from an alarming trend of increasing violent incidents in the community. 

Within the past three years, community-based youth violence has surged, with firearms frequently involved. In 2022, the County Police recovered over 730 guns, including 110 Privately Manufactured Firearms (PMFs). Factors like drug robberies and social media disputes contribute to the violence. Last year saw 20 firearm homicide victims, eight of whom were 21 or younger. Non-fatal shootings injured 73 victims, 30 of whom were 21 or younger. Non-contact shootings have also risen. 

In order to combat this violence, a combination of supportive services, focused police enforcement, and established partnerships for positive youth engagement have been launched in the county. Despite increased funding towards these programs related to youth violence prevention efforts, violence has continued to increase, highlighting the disconnect between government action and community needs. The current approach has not yielded effective systems-based solutions to the problem of violence. Policymakers that lack knowledge of local challenges design system-based solutions that result in significant impact that causes residents to question the use and efficacy of government funds.

Therefore, the Youth and Family Services Department identified a pressing need to establish equitable engagement with all communities, particularly those historically marginalised, to identify the underlying causes of violence and develop comprehensive programmatic solutions that address systemic issues. 

ET4HS allowed Montgomery County to engage in meaningful dialogue with fellow team and cohort members, subject matter experts, and, most importantly, the community they serve. 

Through the program process, Montgomery County recognised that youth violence is a pervasive issue that impacts everyone, regardless of whether they are directly involved in or targeted by such violence. This shift in perspective highlighted a renewed focus on youth as essential members of the Montgomery County community and an acknowledgement that confining understanding of youth within institutional boundaries is a disservice to the public.

After holding community listening sessions with youth, the Collaboration Council, parents, and county employees, team members noted a few common themes among sessions. Common themes included the following:

1. A shared definition of community was lacking among participants, as it is not bound by concrete geographical features. Instead, community was understood as a multi-layered term that signifies social affinity between individuals, even if they do not share physical space as part of the in-group. Community members felt excluded in their own community. 

2. The theme of vigilance, particularly among youth who feel a sense of danger and exclusion in their communities. This feeling manifests in various contexts, such as continuous police surveillance at places like malls, necessitating behavioural adjustments to avoid trouble, and heightened anxiety caused by ambient noises like sirens. 

3. Altercations frequently originate in unmonitored spaces, and the presence of violence in the community is exacerbated by online cyberbullying.

It became clear to Montgomery County that it was essential to deepen community engagement to cover the many intersectional identities of the community and connect with those closest to the challenge of youth violence in order to address root causes. The team plans to use various tools learned in ET4HS moving forward, including utilising historical analysis to ground present observations in the community context and intentionally creating a community listening session framework to encourage the practice of radical listening. Inspired by the experiences of Chile’s La Fábrica de Renca’s embrace of equitable engagement and Australia’s Latrobe Health Advocate and Health Assembly’s data-to-action framework, Montgomery County wants long-term engagement to actively include the collective community in creating solutions. 

In order to reimagine community engagement practices to reassess the approach to youth violence, Montgomery County developed the following recommendations:

1. Create a framework and shared vocabulary around an approach to violence prevention and mitigation.

2. Adopt a framework for sensemaking and cocreation with the community and stakeholders.

To implement recommendations, the Montgomery County team has outlined the following action plan:

• Conduct targeted Community Listening Sessions (CLS) with specific stakeholders to address the diverse identities within Montgomery County's communities. The initial focus will be on engaging individuals residing in areas disproportionately affected by violence, lacking support and infrastructure, or facing safety challenges despite available resources. Through these CLS, the Core Team aims to gather insights and perspectives that will inform the development of equitable solutions for the community.

• Collaborate with journalism experts to analyse and deconstruct the experiences of individuals and groups amidst the rise of violence in Montgomery County.

• Undertake desk research and conduct additional CLS to gain a deeper understanding of how communal trauma, social conditioning, and other influences impact male-identifying youth in Montgomery County.

• Identify potential key partners from various sectors across the County. These partners will be engaged to share findings from the ET4HS program and participate in co-design sessions aimed at addressing communal trauma, fostering a sense of community and resilience, and investing in Montgomery County youth programming and infrastructure.

In Detroit, Michigan, the disability community embraces mental health as an integral part of their collective identity, championing acceptance, empowerment, and holistic care for all. Governments play a crucial role in promoting this culture of care and well-being, especially for the most marginalised and disenfranchised. Over the last few decades, key federal legislations like the Americans with Disabilities Act (ADA) of 1990 and the Affordable Care Act (ACA) of 2010 have been historical moments for the Detroit disability community and beyond. 

Locally, these laws helped tens of thousands gain coverage to treat their conditions for a better quality of life, access preventative measures, and strike down discriminatory policies Detroit residents faced. They also began to address the complex nature of the relationship between health outcomes and what has come to be known as the social determinants of health. 

Unfortunately, addressing health disparities, and mental health in particular, remains a challenge both in Detroit and across the country. According to the CDC, over 17 million adults with disabilities in the U.S. still experienced frequent mental distress in 2018. The COVID-19 pandemic and the associated isolation, disconnect, disrupted routines, and diminished health services have further impacted the lives and mental well-being of all people, especially individuals with disabilities.

Recognising the interdependence between these factors, disability, and mental health, Detroit’s government has strived to provide more comprehensive support systems to its residents. The creation of the Office of Disability Affairs (ODA) in 2021 was both an important milestone for the greater inclusion of the disability community and an indicator of how far the city still has to go to meet the needs of all individuals.

In response, as part of ET4HS, Detroit’s core team set out to assess how social determinants of health impacted not only the mental health and well-being of persons with disabilities in the Detroit and out-county areas but also their ability to access mental health services and resources. Specifically, by centering the voices of those most closely affected by this issue, this partnership between government and community leaders aimed to inform and shape Detroit's commitments to the disability community, paving the way for a society that values and supports the mental well-being of all its constituents.

Through a series of community listening sessions, representatives from the Detroit Health Department, the ODA, and three local community organisations sought the input of 10 Detroit residents that either live with a disability or directly support one or more individuals with disabilities. By thoughtfully engaging with them in an intimate and personal setting, the core team was able to dig deep into where and how trust in the government’s ability to provide adequate care for residents may have been damaged and hear firsthand accounts of the sometimes violent nature of the mental health care system in Detroit.

Throughout those discussions, Detroit residents raised concerns about the city’s transportation system, infrastructure and overall accessibility, the availability of mental health resources, and the policing of mental health. They asked for greater advocacy and representation of the disability community in government and questioned the effectiveness and convenience of the current mental health system as a whole. The most recurring pieces of feedback were:

1. Information about existing mental health services available to folks in the disability community and their support system is either insufficient or not communicated effectively to those who stand to benefit from/use such services.

2. The individuals providing mental health services or who hold information about these services are not well equipped to properly serve persons with disabilities.

Following the example of what has been done in Renca, Chile, or Umuaka, Nigeria, the team held two cocreation workshops with those same residents to brainstorm ways to address the two pain points highlighted above. As a result, the Detroit core team formulated two recommendations based on residents’ feedback for the city’s leadership to promote better health and greater accessibility of mental health services:

1. Create an information page on the ODA’s website that compiles and links to service providers and resources about mental health that will serve as a central hub and a starting point for all seeking care. This will allow the team to have more direct control over both the vetting of resources and the frequency of updates - two key issues raised by residents.

2. Develop and pilot a new training curriculum for city staff to better serve members of the disability community, focusing on strength-based and trauma-informed practices, to address the many reports of negligence and lack of care from residents.

Earned legitimacy calls for a demonstrated commitment from governments to address past harm and rebuild trust through decisive actions involving those most impacted. In order to begin to pave the way for a city of Detroit where mental health services are accessible to all, this core team developed the following action plan:

• By the end of September 2023, the ODA will collaborate with the Health Department and healthcare professionals to develop a Mental Health Resource Guide, specifically designed for members of the disability community, that can be used and shared throughout the city government.

• By the end of September 2023, the ODA will coordinate with the Health Department and the Department of Information and Technology (DoIT) to include a resource page on its website dedicated to this guide.

• By the end of January 2024, the ODA and the Health Department will draft a curriculum for a new sensitivity training that is informed by community members and health practitioners and will explore training opportunities and partnerships within the Health Department to continue this body of work.

As one of the epicentres of the Civil Rights Movement in the 1950s and 1960s, Guilford County’s culture and history are shaped by the inspiring leadership of Black activists who, through sit-ins, protests, walkouts, and legal battles, fought to dismantle oppressive legislation from the Jim Crow era. Today, with its many programs and services dedicated to migrant populations, its prominent LGBTQI+ community, and over 120 first languages spoken in its schools, Guilford County strives to live up to this past and has come to be considered a place of refuge for its over half million residents.

Despite desegregation and other strides to make Guilford County a fair and welcoming home for all, many policies and practices continue to uphold a system of oppression that undermines many communities’ ability to access goods and services that directly impact their health. This is perhaps best exemplified by redlining, which has intentionally kept primarily Black communities within the confines of the most disenfranchised and underserved neighbourhoods across the county over the years. 

Most recently, the COVID-19 pandemic further exacerbated the effects of historical and present systemic oppressions. Its disproportionate impact on people of colour within the community and the surrounding misinformation and disinformation motivated by political divisiveness are painful reminders of the many challenges that remain in earning and sustaining trust between local government and Guilford County’s residents.

Guilford County Health Department believes it is necessary to strengthen the trust with their communities, especially among historically marginalised populations (HMPs). Through the ET4HS program, Guilford County sought to work with community partners and community members to define priorities for the county’s new Access to Care initiative. With guidance from the CPI team, the Guilford County core team’s goal was to deepen their understanding of the factors currently impeding community members’ ability to access healthcare services locally and explore a different framework to incorporate and centre community voices in future county initiatives.

Much like in the rest of the United States, the distrust of HMPs in local government can be traced back to the vast history of oppression in Guilford County. With the support of CPI, this core team conducted a historical analysis to develop a better understanding of the oppressive history that moulded the current relationship between communities of colour and local government. 

Using systems mapping, the Guilford County core team was able to visualise how key stakeholders, community services, and engagement programs were connected to the aforementioned historical events and how these parts of the system eventually led to distrust in the government’s ability to address the needs of all residents effectively. The two main takeaways from this exercise were that: 

1. there are many stakeholders the Guilford County Health Department can partner with to address distrust from HMPs, and

2. residents respond better to community-centred interventions than a traditional “top-down” approach.

Inspired by the work of international participants on gathering community input in Renca, Chile, and in the Latrobe Valley, Australia, the Guilford County core team led listening sessions with eight residents from communities that have historically been underrepresented in the local decision-making processes. There was a strong sense of hope and urgency to improve the relationship with local government; many community members felt that holding these sessions alone was a step in the right direction. However, these discussions led to conclusions that sounded all too familiar. In addition to sporadic efforts to restore trust with underserved communities, the local government is perceived to have excluded their members from the decision-making process by either systematically dismissing the inputs of individuals of colour or by treating them differently entirely. 

For local governments, an important aspect of rebuilding trust with residents is to demonstrate their commitment by turning inputs into solutions and actions. Building upon the community listening sessions, the Guilford County team invited the same residents to cocreate priorities that would improve access to care locally. Over the course of the two virtual workshops, more than 30 community members expressed the need for an expanded public transportation system that reaches the most isolated part of the county and remains accessible for extended hours in order to connect residents to healthcare services, but also to their jobs and other basic necessities. They also provided valuable insights on the composition of a potential future community advisory council that would be remunerated to act as their voice in defining Access to Care by requesting diversity of experience, background, and positional power amongst members that would represent each part of the county.

It is clear that engaging the community, building trust, developing strong and long-lasting relationships with partners, and sharing power are critically important in the process of addressing health disparities in Guilford County. As a result of this program, this core team formulated three recommendations informed by residents for the county leadership:

1. Create a Community Advisory Council to act as the voice of those most impacted by these issues in the community. The Council would sustainably help define the priorities of the county government’s Access to Care initiative.

2. Engage and collaborate with county and city partners to support transportation projects that better connect folks across Guilford County to the health services they need.

3. Leverage the data gathered through this program to inform the county’s future strategic planning process.

In order to continue to restore trust with community members, spearhead these recommendations, and build a healthier and more equitable Guilford County, this core team plans to:

• Present their findings through the ET4HS program to county leadership by the end of July 2023.

• In collaboration with the Quality Improvement government team, establish a framework for a community advisory council focused on defining Access to Care across the county by the end of September 2023.

• By the end of November 2023, develop a plan to institutionalise practices and tools learned during the ET4HS program, such as community listening sessions and cocreation workshops, into the county’s Community Health Assessment processes.

• By July 2024, launch the first iteration of a community advisory council that can guide priorities for our county’s quality improvement process.

Tampa is a complex and historically-rich city located in Hillsborough County on the west coast of Florida. The demographics of the area are mixed, with large numbers of white, Black, and Hispanic people represented. Although the numbers would paint a picture of a diverse city, the strong history of redlining and segregation in Tampa has produced an environment that continues to cultivate disunion, separation, and distrust. Most neighbourhoods in the city tend to house and employ (or not house or employ) predominantly one race or the other, while a historical fear of police and wariness of other government bodies plague minority communities.

Furthermore, Tampa has undergone substantial economic growth in the past decade. According to a benchmark report released in 2018 by the Tampa Bay Partnership, the Community Foundation of Tampa Bay, and the United Way Suncoast, Hillsborough County alone has witnessed the creation of nearly 100,000 jobs since 2014. However, a concerning trend emerged as a significant portion of young individuals aged 16-24 remained disengaged from the workforce. Recognising this issue, the Mayor's Workforce Development Advisory Team took action by establishing The Mayor's Workforce Council in March 2021. 

Despite dedicated resources being allocated to assist unemployed youth, specific communities in Tampa have struggled to benefit from these initiatives due to a deep-rooted lack of trust between marginalised groups and the local government. This lack of trust has created a divide, discouraging these communities from accessing the resources offered by the government. Consequently, the historically Black community of East Tampa has experienced limited opportunities for its youth, who have minimal interaction with the local government. For the past 15 years, the primary job available to the young residents of East Tampa has been manual ground maintenance, such as trash pickup.

In response to community concerns, there is a pressing need to reevaluate work experience programs and outreach efforts in East Tampa. Consequently, Tampa has actively engaged in the ET4HS program, aiming to leverage its tools and insights to foster collaboration with the community and develop sustainable solutions that address the underlying issues contributing to the deterioration of social determinants of health. Recognising that entry-level jobs, such as trash pickup or grounds maintenance, fail to motivate young individuals to pursue meaningful employment and perpetuate a cycle of limited job prospects. Tampa is committed to breaking this pattern. These jobs can be hazardous, offer limited career growth, and lack adequate health insurance coverage, thereby hindering opportunities for better, safer, and healthier outcomes in the long run.

Tampa gained valuable insights from ET4HS programming and international experts who successfully addressed health equity issues in their respective regions. Representatives from Umuaka, Nigeria, highlighted the importance of cocreation in generating lasting change. By involving residents and considering their perspectives, Tampa prioritised community-building and trust with the local government. During cocreation and community listening sessions, participants expressed appreciation for being included, instilling hope for better solutions.

Conducting  community listening sessions, the Tampa core team discovered several key insights regarding the perspectives of the people in East Tampa concerning government trust and work initiatives:

1. A prevalent concern expressed by residents is the fear of reprisal from the government and potential economic marginalisation if they were to voice the truth about their living conditions. Consequently, individuals are compelled to maintain the dissatisfying status quo in order to protect themselves and their loved ones.

2. Another significant sentiment among East Tampa residents is the perception that their community's needs are often overshadowed by those of other communities, primarily due to their racial and socio-economic status. This perceived disparity changes briefly when local politicians seek their votes, as they then feel that their concerns are momentarily acknowledged and addressed.

3. East Tampa residents also expressed a pervasive sense of a lack of autonomy resulting from an imbalance in power-sharing between the government and themselves. They believe that decisions are made on their behalf without their meaningful representation, leading to a diminished sense of control over their own circumstances.

These insights shed light on the underlying issues faced by the community in East Tampa, emphasising the need for proactive measures to address their concerns, foster trust, and promote equitable representation. Recommendations to address community needs are as follows;

1. Listen to the community by speaking to individuals with diverse lived experiences at every level of government processes.

2. Establish a clear vision for goals and strategy prior to implementation. Involving community members and key stakeholders in strategy development can help increase trust and success of programming.

Through cocreation with the community and other government organisations, Tampa used these insights to cultivate an action plan for the rest of the year that was sensitive to and inclusive of all experiences. In order to initiate the process of building trust between the local government employees and the East Tampa community, Tampa plans on implementing the following items by the end of the year.

• The core team plans to host a health and community resource fair for youth in East Tampa. Both community members and outside vendors will run this event. Different organisations will be hiring, and there will be check-ups (for high blood pressure, diabetes, etc.) provided on site.

• Increase communications for a health fair through various channels ranging from posting on social media to using school resources. 

• The Department will partner with the CDC of Tampa to run a safety training with youth to wear PPE and practice safety measures such as wearing high visibility safety vests.

The scientific community has known for centuries the dangers lead poses to young children, with the greatest damage posed to children ages zero to six whose brains are vulnerable to neurological damage from lead. Childhood lead exposure slows development, damages the brain and nervous system, and can result in long-term health, behavioural, social, and economic challenges into adolescence and adulthood. While lead poisoning is seen throughout the United States, it is particularly severe in Memphis and Shelby County. Shelby County has 11 of the top 20 ZIP codes in the state for lead-poisoned children in 2015-2021 and is second in the southeast for childhood lead poisoning, according to the Environmental Protection Agency. 

Data shows that Black, Brown, and low-income children are at greatest risk for lead poisoning. Approximately 300 children annually are identified in Shelby with elevated blood lead levels (EBLs) of 3.5 dl/mg, according to Shelby County Health Department (SCHD), and the majority are African American children who live in older low-income ZIP codes. This is due to the higher levels of environmental lead present in older homes and marginalised communities. This disproportionate effect has been ignored by industry and responsible parties and inadequately addressed by the government and the healthcare sector up to the present day. Strained relationships have remained a continuing issue due to the long-standing experience of disinvestment and racial politics. Many young children are not being tested for lead as it is not currently a universal practice, and many children are likely undiagnosed and unserved as a result. 

Compounding this issue is the fact that there is no existing local map of the complex system that leads prevention and treatment services, which involve dozens of agencies and sectors, including public and private health providers, environmental, housing, code enforcement, water utilities, early childhood development services, education, and juvenile justice. The Shelby County core team’s understanding of government services established to protect and serve families and children exposed to lead is fragmented and incomplete, and this impedes their efforts to improve the efficacy of services across the system as a whole.  In response to this pressing issue, Shelby County focused on the problem of environmental lead contamination and the known and indisputable fact that lead is bad for children.

Based on this uncertain context and referencing more than a dozen interviews and community listening sessions conducted through ET4HS, the Shelby County Team has identified the following problem: “Our understanding of the service sectors that serve families and children at risk for lead exposure is fragmented and incomplete and undermines efforts to identify how the system can be improved.”  

The qualitative data collected during listening sessions provided the team with a comprehensive understanding of the shortcomings of the current provider system in addressing the needs of children and families impacted by lead poisoning. Two key insights emerged from these sessions and sensemaking:

1. Lack of knowledge of lead poisoning: The existing service provider system fails to meet the needs of affected community residents. There is a widespread lack of awareness regarding lead poisoning, as well as an incomplete understanding of the governmental entities responsible for lead prevention and support services.

2. Distrust of government yet hope for government involvement: Community residents harbour mistrust towards the government, perceiving it as unresponsive to their needs, particularly due to their status as residents of communities of colour. However, despite this distrust, the government is seen as a vital component of the solution. It is acknowledged that the government possesses the necessary resources and responsibility to address the lead poisoning issue.

The insights gained from international subject matter experts greatly influenced the team's approach. Lessons from the Latrobe Health Assembly highlighted the significance of prioritising the lived experiences of the community when understanding issues and designing solutions. It emphasised the dynamic nature of advancing health equity, requiring continuous stakeholder engagement in defining and redefining community well-being. Additionally, creative strategies were identified as necessary to include community residents typically excluded from decision-making processes.

Based on these findings, the Shelby County core team recommends the following actions:

1. Identify a trusted backbone agency with the capacity and the mandate to conduct and coordinate family-focused lead education, outreach, and navigation services.

2. Conduct a cross-sector environmental scan of all agencies’ roles & responsibilities for lead poisoning prevention & services to identify service gaps

Moving forward, Shelby County has outlined the following next steps:

• Presenting the Capstone findings and intended next steps to stakeholders at the August 2023 Healthy Homes Partnership and Lead Commission meetings, with the aim of increasing awareness of the project.

• Establishing cross-departmental and federal relationships: In the year ahead, the team will request meetings with key governmental agencies, including the Shelby County Health Department, City of Memphis Division of Housing & Community Development, Shelby County Housing Department, MLGW staff and Community Advisory Board, and state officials from Tennessee Early Intervention and Development Services and Tennessee Department of Health. These meetings will involve sharing the capstone report findings and exploring their involvement in the environmental scan process.

Program analysis: reflecting on and improving the ET4HS experience 

As a learning partner, CPI evaluates our programs holistically to understand overarching themes, achievements or strengths of the program, challenges faced during the program, and areas of improvement. These insights are applied to future CPI programming and can be used by other organisations seeking to work with governments to advance health equity.

Program themes 

Through the evaluation of action plans from six participating cities and counties, recurring themes emerged that underpin a commitment to enhancing access to healthcare and services, fostering robust community engagement and trust-building, promoting collaborative partnerships, and embracing data-driven decision-making.

• Continued focus on improving access and services: City teams plan on finding solutions to improving access to essential services and addressing health disparities. Examples of this theme include improving mental health services and accessibility, transportation access to health services, health and community resource fairs, and outreach initiatives. 

• Community engagement and trust-building: Each team recognised the importance of engaging with the community and building trust. Action plans highlight a need to deepen community trust through a variety of engagement strategies such as establishing advisory councils, conducting community listening sessions, partnering with community organisations and stakeholders, involving youth in decision-making processes, and running outreach initiatives. Cities and counties underscore the importance of actively involving community members in shaping policies and establishing trust between local government entities and the communities they serve.

• Data-driven decision-making: Several teams mention the importance of utilising data and research findings to inform strategic planning and decision-making. This includes conducting environmental scans, incorporating program data into future planning, and resetting health equity indicators. Data-driven approaches help ensure that policies and initiatives are evidence-based and responsive to community needs.

Program achievements

Guided by an unwavering commitment to building community trust and health equity, ET4HS made an indelible mark on participants. The learning cohort was empowered to cultivate lasting community relationships, collaborate across departments to create sustainable solutions and apply programmatic lessons to future initiatives.

• Cultivating community relationships for lasting impact: ET4HS served as a catalyst for local governments in laying the groundwork for establishing stronger and enduring relationships within communities. Participants expressed the invaluable insights gained through conversations with community members, shedding light on the challenges and realities faced on the ground. Leading community listening sessions and cocreation workshops with residents highlighted the pivotal role of community engagement in driving sustainable, long-term change. In response to this recognition, ET4HS participants actively developed projects that prioritise the ongoing cultivation of community relationships and trust.

  Cities like St. Louis and Guilford County took proactive steps to deepen their connections with the community through various initiatives. St. Louis, for instance, formulated a comprehensive plan to conduct a listening tour, building upon the outcomes of the community listening sessions. The primary goal of this tour is to foster bilateral listening between the health department and the alderpersons, fostering an environment of open and constructive dialogue. Importantly, this initiative strongly emphasises the critical role of community input in shaping departmental strategies. Similarly, Guilford County recognised the value of insights derived from community members and utilised this knowledge to inform the composition of a future community advisory council. By actively involving the community in decision-making processes, Guilford County ensures that its initiatives align with the needs and aspirations of the community it serves. 

• Promoting cross-departmental collaboration: another achievement of the program was fostering departmental collaboration. Participants appreciated the opportunity to work intentionally with their coworkers and colleagues from different departments. As a result, many participants established relationships with team members they were previously unfamiliar with, promoting a sense of cooperation and highlighting the potential for cross-departmental solutions. 

  Montgomery County pulled team members together from different departments to tackle the root causes of youth violence in the county over the course of ET4HS. By bringing together team members from various departments, participants had the chance to work intentionally with colleagues they hadn't previously interacted with. This collaborative approach allowed for a more comprehensive and holistic understanding of the issue. Often, complex issues such as youth violence require a multi-faceted approach. By bringing together individuals from different departments, the program was able to leverage a diverse skill set and knowledge base. This facilitated the exploration of innovative and comprehensive solutions that may not have been possible within the confines of individual departments. The core team plans to continue this cross-departmental partnership in order to build a cocreation and sensemaking framework.

• Applying program learnings for impactful work: the ET4HS learning space allowed government officials to acquire new skills and strategies for the future. Over 90% of survey respondents say they plan on using skills learned in everyday work. 

  Guilford County specifically plans to integrate historical analysis into new employee orientations, ensuring that employees are informed about the historical context prior to engaging with the community. Additionally, Detroit and Montgomery County plan to implement community listening sessions and sensemaking workshops to actively gather community input and facilitate collaborative decision-making processes. 

Program challenges

As the inaugural ET4HS program comes to a close, it is evident that the path to building community trust and health equity for local governments is not without its share of obstacles. By candidly addressing challenges that emerged throughout the program, future program iterations can enhance efforts in advancing health equity and promoting a Culture of Health.

• Time constraints for relationship building and staff capacity: Participants in the program highlighted challenges related to time constraints for relationship building and program deliverables. Many expressed the need for more dedicated time and even mentioned the desire for a sabbatical to fully immerse themselves in the program. Balancing regular work responsibilities alongside program commitments proved difficult, impacting participation and the ability to connect with other cities and counties. Participants felt that more time should have been allocated to practical implementation, such as conducting community listening sessions and focusing on deliverables. They suggested a more focused approach with fewer topics covered in each session, allowing for deeper exploration and peer connections. Extending the program duration would have provided the necessary time to build relationships, meet deliverables, and better integrate program outcomes into their work.

• Additional buy-in needed from senior leadership: while the program helped teams lay the groundwork towards significant progress, it is acknowledged that additional buy-in from senior leadership is necessary to drive meaningful change. Senior leadership plays a crucial role in setting the tone and direction of the department and city, and their support is essential in prioritising and allocating resources to initiatives aimed at advancing health equity. By securing the commitment and support of senior leaders, participants can ensure that their efforts receive the necessary resources, visibility, and endorsement to effect significant and sustainable change. Engaging senior leadership earlier on in the timeline through effective communication and showcasing the potential impact of ET4HS can help garner their buy-in and create a shared vision for driving health equity.

Program improvements

We recognise that there are ways to improve the experience for our participants by modifying components of the program’s design. The following section provides a brief analysis of some of the key highlights and opportunities for enhancement moving forward:

1. Improving collaboration and tailoring curriculum: incorporating pre-program activities, such as team-building and collaboration discussions, allowed participants to form relationships, discuss ideas, and align expectations before the official program launch. These activities, embedded in the ET4HS orientation sessions, facilitated stronger participant bonds. However, dedicating additional time to team planning would have further improved their collective effectiveness. Through this journey, learning liaisons and participants witnessed the gradual building of trust and a renewed sense of purpose within their teams. Moreover, future iterations must adapt the curriculum to participants' diverse backgrounds and knowledge levels. This would ensure it met specific needs, equipping participants with relevant knowledge and skills to address health equity challenges in their communities. 

2. Extended timeline for strengthening trust and building connections: the program's focus on building trust with the community necessitates dedicated time and ongoing efforts. While the 15-week duration provided a strong foundation, expanding the program timeline would allow for additional intentional work on deliverables and flexibility to meet evolving resident needs. This program serves as the first step towards earning legitimacy and creating lasting impacts on health equity, but it is crucial to recognise that it is just the beginning of shifting perspectives. To foster long-term transformation, the emphasis should shift from deliverables to fostering deeper connections and collaboration. Encouraging cross-sector interactions, knowledge exchange, and organising site visits for in-person learning among teams would enrich the program and enable innovative problem-solving towards holistic solutions. By strengthening trust, building connections, and emphasising collaboration, the journey towards health equity can be advanced effectively.

3. Connecting perspectives and strengthening practical application: incorporating international perspectives and office hours provided valuable avenues for participants to connect with guest speakers, exchange contacts, and gain insights and frameworks used in varying contexts. We recommend increasing the frequency of local and internationally-led workshops or learning sessions to further bridge the gap between abstract concepts and real-world applications. This expansion will facilitate translating knowledge into practical strategies, nurturing a deeper understanding of health equity. We recognise additional learnings may also be supported through a reconfigured program timeline. Moreover, the organisation can play a vital role in facilitating additional touchpoints to support ongoing learning and collaboration.

4. Ensuring sustainable impact: incorporating an additional implementation phase: we propose incorporating an additional implementation phase following the program’s Capstone Days for at least three months of lighter-touch support. Core teams would have an opportunity to begin to roll out their action plans while still utilising the resources provided by CPI, which includes continued input from a dedicated learning liaison and direct access to international participants and subject matter experts. This hands-on experience is invaluable as it allows program participants to navigate real-world challenges, adapt their strategies, and leverage the expertise and resources provided by CPI. Only through implementation can participants truly gauge the feasibility and effectiveness of their proposed solutions. The additional support may help address any unforeseen obstacles that may arise during implementation. This phase can bridge theory and practice, allowing participants to strengthen their initiatives, ensuring sustainable and impactful outcomes for their communities.

Conclusion  

The ET4HS program provided participating municipalities with some necessary tools to equitably approach community engagement to foster trust in their journey toward advancing health equity. However, it is important to recognise that this program is just the first step in a much larger journey. Health equity is a multifaceted, ongoing challenge that requires sustained commitment and continuous efforts. This program created a space for learning, sharing innovative solutions, and starting to build trust among stakeholders. 

While we celebrate the accomplishments and progress made through the ET4HS program, we must also acknowledge that there is much more work to be done. This program serves as a starting point, a call to action to further refine and expand our efforts in advancing health equity. By fostering an environment of collaboration and embracing the need for change, we pave the way towards a future where health disparities are eliminated and everyone can thrive. 

Partners, participants, and supporters

About the Centre for Public Impact

At the Centre for Public Impact, we believe in the potential of government to bring about better outcomes for people. Yet, we have found that the systems, structures, and processes of government today are often not set up to respond to the complex challenges we face as a society. That’s why we have an emerging vision to reimagine government so that it works for everyone. 

A global not-for-profit organisation founded by the Boston Consulting Group, we act as a learning partner for governments, public servants, and the diverse network of changemakers who are leading the charge to reimagine government. We work with them to hold space to collectively make sense of the complex challenges we face and drive meaningful change through learning and experimentation.

About Robert Wood Johnson Foundation

The Robert Wood Johnson Foundation (RWJF) is committed to improving health and health equity in the United States. In partnership with others, RWJF is working to develop a Culture of Health rooted in equity that provides every individual with a fair and just opportunity to thrive, no matter who they are, where they live, or how much money they have.

Health is more than an absence of disease. It is a state of physical, mental, and emotional well-being. It reflects what takes place in our communities, where we live and work, where our children learn and play, and where we gather to worship. That is why RWJF focuses on identifying, illuminating, and addressing the barriers to health caused by structural racism and other forms of discrimination, including sexism, ableism, and prejudice based on sexual orientation.

RWJF leans on evidence to advance health equity. They cultivate leaders who work individually and collectively across sectors to address health equity. RWJF promotes policies, practices, and systems change to dismantle the structural barriers to well-being created by racism. And they work to amplify voices to shift national conversations and attitudes about health and health equity.

Through their efforts, and the efforts of others, RWJF will continue to strive toward a Culture of Health that benefits all.

For more information, visit www.rwjf.org.

About ET4HS program

In the 2023 cohort, six local governments joined with community partners to address issues ranging from inequities faced by the disability community to lead contamination to building trust for greater collaboration. Selected cities and counties include Detroit, Michigan; Guilford County, North Carolina; Montgomery County, Maryland; Shelby County, Tennessee; St. Louis, Missouri; and Tampa, Florida.

ET4HS connects these U.S. governments to a global network advancing solutions for health equity. Our 2023 international partners include Butuan, Philippines; Latrobe Valley Health Assembly, Australia; Latrobe Valley Health Advocate, Australia; Lusaka, Zambia; La Fábrica de Renca, Chile; and Umuaka, Nigeria.

Cities and team members

Detroit, Michigan

Detroit’s health equity issue focused on providing better access to mental health services for the disability community and their support system. 

Team members are as follows: 

• Christopher Samp, Office of Disability Affairs, Director

• Hallie Berinstein, Office of Disability Affairs, Assistant

• Marisa Spain, Office of Disability Affairs, Policy Research Assistant

• Renata Polk, Health Department, Clinical Operations Manager, Lead Program

• Megan Boyce, Health Department, Clinical Division, Reproductive Health Program Manager

• Angel Reed, Health Department, Maternal Infant Health Division, Public Health Program Manager

• Camille Proctor, Local Community Partner, Color of Autism Foundation, Executive Director

• Nia Anderson, Michigan Developmental Disabilities Institute, Research Assistant 

• El Johnson, Wayne State University, MSW Candidate 

• Anthony Zander, Civil Rights, Inclusion and Opportunity Department, Director

Guilford County, North Carolina

Guilford County, North Carolina’s health equity issue focused on defining “Access to Care” for their community to inform policy-making decisions to reduce the stark local disparities. Team members are as follows: 

• Jacob French, Health Equity Coordinator

• Monet Kees, Every Baby Guilford, Health Equity Manager

• Eli Saavedra, Healthy Communities Coordinator

• Stephanie Staley, Guilford Community Care Network, Provider Outreach Program Manager 

• Lisa Duck, Guilford Community Care Network, Executive Director 

Montgomery County, Maryland

Montgomery County’s Health and Human Services Department focused on improving its services to better address the needs of youth residing in areas with high levels of youth violence. Additionally, there is a lack of knowledge regarding the effectiveness and utility of the existing programs currently offered by the county. Therefore, there is a need to assess and evaluate the effectiveness of these programs to determine if they are truly impactful in addressing youth violence and meeting the needs of the affected communities.

Team members are as follows: 

• Dira Treadvance, Children, Youth, and Family Services, Chief 

• Hannah Shaw, Family Investment Supervisor, Department of Health and Human Services

• Marcus Gaddy, Program Manager, Department of Health and Human Services

• Yvonne Iscandari, Administrator, Department of Health and Human Services

• Jenai Bell, EAA, Department of Health and Human Services

• Nidhi Singh, Civic Design Lead

• Rhiannon Reeves, Montgomery County Government, Office of Racial Equity and Social Justice, Program Manager, Policy Analysis

Shelby County, Tennessee

Shelby County, TN, had a health equity focus on improving the collective knowledge of lead contamination and service systems across the county. 

Team members are as follows: 

• Connie Binkowitz, Center for Transforming Communities, Director of Development & External Policy

• Dana Sjostrom, Shelby County Housing Department, Manager, Planning & Programs

• Chet Kibble, Memphis & Shelby County Lead Safe Collaborative, Founder/Director

• LaTricea Adams, Black Millennials for Flint, Founder/President

• Sharon Hyde, Green & Health Homes Initiative, Program Manager

• Cathy Marcinko, Methodist LeBonheur Healthcare, Grant Development Director

• Paisley Pogue, Clerical Specialist, Department of Housing

• Desiree Burroughs-Ray, Academic Hospitalist, Methodist Le Bonheur Healthcare 

St. Louis, Missouri

The city of St. Louis focused on the following questions around their health equity: How can the City of St. Louis effectively engage and motivate the city government and communities to support and execute an equity plan while enhancing links between the city and its communities? What are the key priorities and expectations of communities from the Department of Health (DOH) in promoting health equity and improving health outcomes? Furthermore, how can the DOH strengthen its partnership with communities and provide support to enhance health outcomes for the community and its partners?

Team members are as follows: 

• Julie Gary, City of St. Louis Department of Health, Bureau Chief, Behavioral Health

• Cory Bradley, PhD, Implementation Consultant, Institute for Public Health at Washington University

• Hannah Robinson, CDC Associate, City of St. Louis Department of Health

Tampa, Florida

The city of Tampa, Florida’s Diversity Coordinator, Rugina Castillo, focused on opportunities that can be given to youths to address the youth unemployment issue that is inhibiting them and their families from receiving access to quality health care. 

Global Perspectives: thought partners and international subject-matter experts 

The thought partners for the ETH4HS program included six international subject-matter experts who added an international perspective to different health equity issues being addressed around the world. Topics ranged from narrative change to conducting research to equitably cocreating solutions with the community. 

International subject matter experts were split into two levels, A and B, based on the number of engagement opportunities with U.S. participants. Level A included experts from Renca Chile, Latrobe Valley, Australia, and Umuaka Nigeria, who connected with the cohort on multiple occasions, leading sessions directly and hosting small group office hours to delve deeper into their presentation topics. Level B included speakers from Butuan City, Philippines, and Lusaka, Zambia, who shared pre-recorded presentations during a cohort meeting around a specific topic.

International subject matter expert profiles

LEVEL A

Renca, Chile: How to Equitably Engage Community Members and Learning Partners

Javier Morales is the Executive Director of La Fábrica de Renca. He is an industrial civil engineer with a specialisation in Environment from Universidad Adolfo Ibáñez and Master in Economics Applied to Public Policy from Universidad Alberto Hurtado & Fordham University. In his career, he has been Executive Director of the Fundación Junto al Barrio, Deputy Director of Community Development in the Municipality of La Pintana, and Regional Director for the Metropolitan area of TECHO Chile Foundation.

Carolina Torres is the head of International Relations at La Fábrica de Renca. Carolina has a Business Administration and Economics degree from Universidad de Concepción (Chile) and a master’s degree in finance from Universidad de Chile. With vast experience in the public and private sector, she has worked as a Financial/Economic Analyst at the Central Bank of Chile, Senior Advisor to the Executive Director for Chile at the Inter-American Development Bank in Washington D.C., and as International Finance Advisor at the Ministry of Finance of Chile as well as Deputy Project Manager at SOFOFA HUB and as Chile-US Project Coordinator at AMCHAM Chile.

Joselyn Letelier is the head of the Center of Government at the Municipality of Renca. Joselyn has a degree in Business Administration and Economics from the Pontifical Catholic University of Chile and a Master’s in Public Management and Policies from the University of Chile. She has worked in education at the Pontifical Catholic University and in the Municipality of Renca, where she led different projects related to health, institutional modernisation, and education such as the 75+ program for older people, Centinela project, to track covid. 

Summary of Insights and Key Takeaways:

What: Renca has incorporated community feedback into its innovation and service improvement efforts. Three notable examples include establishing La Fábrica, developing green areas to tackle climate change, and implementing innovative measures to combat the COVID-19 pandemic. In each case, community input played a central role, gathered through surveys, town halls, workshops, and interviews.   

How: The Renca team emphasised the importance of cross-sectoral stakeholder engagement in driving change. In particular, their work illustrated how public-private partnerships can support and build upon residents’ inputs by actively driving the implementation process through funding, expertise, and volunteer time. 

Takeaway: Power of Community Engagement - Renca sets an example of prioritising community involvement in developing new initiatives and effectively engaging residents at every stage. They demonstrate strategic thinking by identifying and utilising various community assets through collaborations with nonprofits and the private sector. 

Latrobe Health Assembly, Australia: Empowering Communities, Transforming Health

Ellen-Jane Browne is currently the Executive Officer of the Latrobe Health Assembly, a place of community-informed health innovation situated in Victoria's Latrobe Valley. Ellen-Jane brings to the role a long history of working in the university and government sectors. Ellen-Jane is skilled in policy analysis, public administration, conflict resolution, systems change, stakeholder engagement, and facilitation. She holds a BA, BA(First Class Hons), Dip Management, Executive Masters Public Administration (ANZSOG) focused on Sociology, Political Science, and Public Administration from Monash, RMIT and Melbourne Universities. Ellen-Jane has worked in the Latrobe Valley for the past six years, having returned to the Valley as Principal Advisor for the establishment of the Latrobe Health Innovation Zone. Whilst with the Department of Health and Human Services, she also assumed responsibility for managing placed-based health programs in the Department's Inner Gippsland Region before resigning in early 2020 to take on the CEO role at the Latrobe Health Assembly. 

Tanya Rong is an Intensive Care Nurse, PhD Candidate, and Public Health Specialist who is passionate about community health and wellbeing and is a strong advocate for community voice in decision-making.  She brings determination, curiosity, and optimism to her role as Chair of the Board of Latrobe Health Assembly, as well as a diverse range of knowledge and health expertise in public health, social innovation, and systems thinking.  Tanya's PhD aims to develop a best-practice framework for place-based approaches to improving health and well-being in areas of poor health and disadvantage. She holds a Masters in Intensive Care Nursing, Bachelor's of Health Promotion with Honors, and is a graduate of the Australian Institute of Company Directors (AICD). 

Summary of Insights and Key Takeaways:

What: The Latrobe Valley endured a 45-day mine fire, causing immediate health issues such as bleeding, headaches, respiratory illness, and distress. Additionally, worries arose regarding the long-term health effects on the community. The government’s handling of the situation resulted in distrust among the residents, making it a devastating event for Latrobe Valley. The Latrobe Health Assembly emerged as a community-led organisation, serving as a voice for the community. 

How: The LHA cocreates solutions by ensuring inclusive participation and conducting extensive consultations. They forge collaborative partnerships with local organisations and hold co-design workshops to involve the community in decision-making. Through these practices, the Assembly fosters community ownership and tailors solutions to meet the specific needs of the Latrobe Valley Community.

Takeaway: Empower and Share Knowledge

Respect the lived experience of the people you bring in and work with. We’re forever changing and forever seeking ideas which creates an opportunity for reinvigoration and a reimagination of what health and well-being can look like. Lastly,  while the “ noisy” people are often heard and seen, it is just as important to engage with the quiet people- the quiet people and the people who are less likely to contribute.

Latrobe Health Advocate, Australia: Building a Bridge from Community to Government  

Jane Anderson was appointed as the Latrobe Health Advocate by the Minister for Health in 2018. Jane provides community-wide leadership by enabling, mediating and advocating for health improvements. In 2019, Jane was appointed Chair of the Latrobe Valley Asbestos Taskforce, which was established by the state government to review how asbestos is managed in the Latrobe Valley. Jane is a member of Regional Partnerships Victoria, a committee member of Gormandale Community House, and a former Board Director of Lifeline Gippsland. Previously, Jane was the Regional Director of Anglicare Victoria for 12 years and a practising lawyer for 7 years in private and community settings. Jane served with Victoria Police for 11 years in roles including prosecutor, investigator, and general police officer.

Summary of insights and key takeaways:

What: Latrobe Valley faces health challenges with below-average life expectancy, high rates of chronic illness, mental health issues, and more. The Latrobe Health Advocate provides independent advice to the Victorian Government, representing the community on health-related policies. Jane, in this role, leads community-wide efforts to improve health through system enhancements and advocacy.  

How: Jane Anderson meets residents where they are. She leads a bus outreach initiative to gather community feedback on how to improve the health and well-being in the community.

Takeaway: Meet residents where they are

Engaging the community involves more than just listening. It requires understanding the context in which people live. It is crucial to act on the feedback received to truly empower the community. To avoid consultation fatigue, it is important to meet people where they are at a convenient time and make the process easily accessible for them. 

Umuaka, Nigeria: Narrative Change

Dr. C’fine Okorochukwu is the founder and president of the Centre for Public Health, an NGO with Special Consultative Status with the United Nations Economic and Social Council. He was the convener of "CPH Ten Million Voices," which is now operating in 26 countries with over 4,500 volunteers spreading the message of Universal Health Coverage. C'fine is a medical practitioner, public health expert, and behavioural change communicator with 23 years of experience working with the Nigerian government, the Centre for Public Health at Lehigh University (USA), the UN, and more. He holds a Bachelor of Medicine, a Bachelor of Surgery (MBBS), a Master of Public Health (MPH), and a variety of certificates in Public Health, Addictions, and Community Engagement. This unique strategy has been tested in Umuaka City, Njaba LGA, and Imo State, funded by Bloomberg Philanthropies, during the 2021 Global Champion City Challenge.

Lesley Agams is a lawyer, author, and social entrepreneur in Nigeria. She has worked in the social justice sector for more than 30 years. She is currently the program director for the Women's Crisis Centre in Imo State, where she leads and supports community development in Umuaka. Her professional focus is gender equality and economic justice for women. Locally and nationally, she’s collaborated to build a legal and policy framework for violence against women and children and is an expert litigator in the field. Internationally, she has contributed to the development of safeguarding and sexual harassment policies in the humanitarian field. In 2021, she led Umuaka to the semifinals of the Bloomberg Mayors Challenge. The project team developed reporting tools for GBV, a community health insurance scheme, and a microfinance scheme for women.

Summary of insights and key takeaways:

What: Created an app, CHIP, targeted at addressing gender-based violence that allows for the community to bypass systems that have worked to keep them silent.

How: Engaging the community through partnerships is essential, involving influential individuals who understand the community ecosystem. Representation is crucial, such as women addressing women’s issues. Community champions and advocates drive meaningful change. 

Takeaway: A trauma-informed approach is essential to reaching the community. Cocreating solutions with the community builds empowerment and motivation, employing a trauma-informed approach to meet people where they are and reshaping the narrative while respecting cultures and beliefs. 

LEVEL B

Lusaka, Zambia

Bwalya Elisabeth Funga Ndolesha is a seasoned professional, bringing exceptional skills developed over ten years of industry experience in urban and social economic planning, community engagement and empowerment, research, gender, and social inclusion, local area planning using a human rights-based approach, monitoring and evaluation, transportation, HIV/AIDS, climate change, and facilitation both at the local and international level. She leads local and international organisations that include the GIZ (in Leipzig, Germany), Transformative Urban Mobility (TUMI), Urban Pathways, United Nations Development Programme (UNDP), WWF, UNAIDS, UNZA, CO-WATER, and many more. 

Email: bwalyafunga@gmail.com

Kachikoti Banda works as Assistant Director of Public Health for Lusaka City Council, Lusaka Zambia. He holds a Master of Engineering in Environmental Engineering degree from the University of Zambia and is currently finalising his Ph.D. from the same institution. Kachikoti has also undergone specialised training in Municipal Solid Waste Management from Japan. A Registered Engineer and Environmental Health Officer, Kachikoti is also the Project Coordinator for the four-year (2022-2025) JICA Lusaka Clean City Project. He is also undergoing City Leadership Training under the Bloomberg Harvard program in the United States. Kachikoti is a Pan-Africanist, avid reader, and a family man.

Vwambanji Namuwelu is the Environmental Planner at Lusaka City Council with over eight years of experience working in the Local Government. She has worked for the Local Authority as a Water and Sanitation Coordinator, coordinating water and sanitation activities in the District and as Environmental Planner with the duty of mainstreaming environmental issues in the development programmes and projects that happen within the District. She has experience in Local Area Planning, Integrated Development Plan formulation, and City Resilience Action Planning. She has a Master’s Degree in Environmental and Natural Resources Management, a Bachelor’s Degree in Environmental and Natural Resources Management, and a certificate in Rural Water Supply and Sanitation and Monitoring and Evaluation. Her hobbies include gardening, cooking, and singing.

Charity C. Kalombo is the vice president of the Zambia Institute of Planners and the Senior Community Development Officer of the Lusaka City Council. She has been involved in economic-related and livelihood programs, including the formulation of slum upgrading strategy and the launch of the resource mobilisation strategy to achieve sustainable development.  She is a Strategic Stakeholder Relationship Builder, driving advocacy and engagement with partners, the government, and donors for increased investment and multi-sectoral collaboration in informal settlement upgrading and community engagement.  She is an expert in inclusive political leadership and community development with outcomes such as improved governance, sustainability, and ownership of programmes within urban space. 

Butuan, Philippines

Pierre Anthony D. Joven (Panpan) leads the City Agriculturist Office of Butuan City, Philippines.  Aligned to the city’s vision as a great hub city of opportunities by positioning Butuan as a smart agri-eco city, he coaches work teams to enable farmers and fisherfolks to be self-reliant and make smarter decisions by demonstrating appropriate farming technologies and agribusiness models from evidence-based research data. His 25 years of experience in public service is coupled with post-graduate training in advanced agriculture in Israel and a Master’s degree in International Development Engineering from the Tokyo Institute of Technology, Japan. Currently, he is the Project Lead of AgriBOOST which is recognised as one of the 15 grand winners of 2021 Bloomberg Global Mayors Challenge.

U.S. Subject Matter Experts

Cassie Rowe: Cassie is the Co-Director of Survivor Wellbeing at the North Carolina Coalition Against Domestic Violence (NCCADV), where she manages a statewide housing program for survivors experiencing homelessness. She has also directed NCCADV’s work to address the health impacts of intimate partner violence for the past seven years. Cassie earned a Master of Public Health at UNC Chapel Hill and worked in global health prior to joining NCCADV in 2015.
Jerry Hawkins: Jerry Hawkins is the Executive Director of Dallas Truth, Racial Healing & Transformation (DTRHT), part of a national 14-place initiative by The W.K. Kellogg Foundation. Dallas TRHT's mission is to create a radically inclusive city by addressing race and racism through narrative change, relationship building, and equitable policies and practices. Jerry is also a co-founder of The Imagining Freedom Institute (The IF Institute), a national research-based leadership group that helps organisations and institutions understand the historical context of contemporary issues of place, race, and space. Jerry was formerly the Project Director of Bachman Lake Together for The Dallas Foundation and Zero To Five Funders Collaborative, an early childhood collective impact initiative in Dallas, and Director of Children's Services at the Wilkinson Center in East Dallas/Southeast Dallas.

Report authors

This report was authored by Elysse Alvarado, Felix Ferrandis, Giselle Cordero, Nicole Hildreth, and Valerie Odonkor.