5 Opportunities and Challenges in Efforts to Boost Health Equity

When it comes to boosting the nation’s focus on health equity in policymaking, leaders in the fields of health impact assessment (HIA) and the Health in All Policies (HiAP) are making advancements to ensure that all people have the opportunity to be as healthy as possible. The term health equity represents the guiding policy principle that disparities in health outcomes caused by factors such as race, income, or geography should be addressed and prevented.

HIA and HiAP, meanwhile, represent two of the key strategies for making that happen. HIA is a process that engages stakeholders to help communities and decision-makers identify the potential health effects of the decisions they make, and HiAP is a collaborative approach that seeks to integrate health considerations into policymaking across sectors to improve public health and health outcomes.

At a December meeting convened by the Health Impact Project, a collaboration of The Pew Charitable Trusts and the Robert Wood Johnson Foundation, 25 leaders and practitioners shared knowledge, identified goals and next steps, and acknowledged successes and challenges in the field.

Five key takeaways offer a roadmap for where practitioners should focus their efforts:

1. Practitioners should support broader efforts to address systemic racism as a driver of health inequities.

The public and policymakers are increasingly aware of the wide inequities in health outcomes by race and ethnicity. Those working in the HIA and HiAP realms should link their focus on health equity with broader efforts to reduce racism and other systemic factors that negatively affect the health of people of color. Hundreds of cities, counties, and states have declared racism a public health crisis, recognizing how structural disadvantages in areas such as housing, education, and employment have driven inequities in disease and mortality by race and ethnicity. Yet not all regions of the country—including some with deeply rooted racial inequities—acknowledge the impact systemic racism has had on health outcomes.

HIA/HiAP practitioners work to gather diverse stakeholder perspectives and to better understand the social, political, and cultural context of proposed decisions. They can use these strengths to determine how to best work toward systemic changes within the unique decision-making environment of their jurisdictions.

The Institute for Healing Justice & Equity, an initiative working to eliminate systemic disparities through systems change and deep community partnership, offers leading practices to support municipal and state governments in sustainably advancing racial equity. These include defining racism as a system in laws and policies; providing material, institutional, and social support to address generational inequities in wealth; and using racial equity tools in government decision-making processes, among others. HIA and HiAP practitioners can also add value to these efforts through their expertise in assessing and addressing social determinants of health, encouraging community engagement, and evaluating proposed policies from a health equity perspective.

2. Diverse application of HiAP approaches and tools are a key strength of the field.

In Santa Fe, New Mexico, for example, Chainbreaker Collective, an economic and environmental justice organization, has used HiAP tools as part of its community organizing efforts to address housing instability. The government of Washington, D.C., meanwhile, is using a new approach called health equity impact reviews to examine how neighborhood and small-area land use plans may affect health outcomes linked to factors such as transportation and park access. These efforts highlight that HiAP approaches can be flexibly adapted and applied to meet the needs and goals of specific communities and jurisdictions.

3. HiAP practitioners continue to face challenges in expanding and growing their work.

The field often faces difficulties identifying sustainable funding streams, and must contend with limited capacity and money to address public health issues, especially in light of the toll the pandemic has taken on public health systems. Practitioners must focus renewed interest, attention, and resources on community health needs that may have been put on hold because of COVID-19.

The funding opportunities that do exist are often siloed, making data sharing or partnership across government agencies more difficult. And sometimes the specific programs restrict practitioners from funding critical community engagement efforts. Because factors affecting public health tend to cross many sectors—including the environment, housing, education systems, and more—such a patchwork approach can prevent collaboration and be detrimental to achieving better health outcomes.

4. There is value in incremental change.

HiAP practitioners highlighted the importance of working to meet small, achievable benchmarks. For example, participants described how government agencies can encourage change by examining the implementation of their existing policies from a health equity perspective, and changing the procedures and processes within their control. Similarly, those working in community organizing stressed the critical need for public health and government partners to build trust and demonstrate their commitment to residents, a foundation for effective collaboration. Over time, these relationships among agencies and community partners can yield important legislative and regulatory changes to protect and promote residents’ health.

5. HiAP practitioners must continue to leverage various forms of evidence, including compelling stories about people’s lived experience, and use them to inform decision-making.

Some participants reported difficulties when trying to reach their targeted audiences with qualitative evidence gathered from communities they work in, when other agencies and organizations provide quantitative data and statistics. The Minimum Elements and Practice Standards for HIA, guidance produced by the Society of Practitioners of Health Impact Assessment, emphasize the importance of multiple sources of evidence in these assessments, including local knowledge and the expertise and lived experience of stakeholders. Such information can play a critical role in helping policymakers understand potential barriers and solutions to health within communities. It also can provide insights that help interpret quantitative findings and develop recommendations. HiAP practitioners should assess a range of data sources when examining the potential public health and equity impacts of decisions.

Compared with a decade ago, practitioners today see a greater interest in health equity and an acknowledgment of the social determinants of health, in part because of tools like HIA and HiAP. The federal government has demonstrated a commitment to addressing these issues, as evidenced by the bipartisan Infrastructure Investment and Jobs Act and the Environmental Protection Agency’s new national office focused on environmental justice and civil rights. Such efforts send an important message to those in the field nationwide working to improve public health through policy changes; adequate funding to address the social, economic, and environmental factors that shape health; and community buy-in and engagement.

Ruth Lindberg directs the Health Impact Project, a collaboration of the Robert Wood Johnson Foundation and The Pew Charitable Trusts.