Organizing Health Equity Work By Place

You’ve probably heard that a person’s zip code can tell us a lot about how long they might live. This is because different places have different resources like public parks and grocery stores and different histories of investment or disinvestment in things like housing, businesses, and schools. Because these social and structural drivers of health inequities are geographically distributed, the way health systems and payers organize to respond to these inequities have to be—at least in part—place-based too. One way this can happen is through Health Equity Improvement Zones.


This model, adapted by HealthBegins for health systems and payers, was directly inspired by a state-level strategy called Health Equity Zones, defined by vanguard states as a designated geographic area where a community identifies and eliminates specific health inequities, working with a coordinated set of institutional partners to effectively broaden and deepen their impact in a specific place. Diverse partners–such as community-based organizations, healthcare systems, and public health departments–align their efforts and resources to build infrastructure for health equity work and to empower communities to represent themselves. Conceptually, this approach shares similarities with other large-scale, geographic, cross-sector strategies such as Communities of Opportunity (as David Williams and others have defined), and Purpose-Built Communities.  


In addition to approaching this work by place, these state-defined Health Equity Zones emphasize:


  • Shifting power and resources to communities, so that they can define what issues are most pressing for their health and wellbeing and design the solutions they want implemented while also de-emphasizing historical systems of power;
  • Amplifying impact by aligning the work of many organizations that have historically worked separately and competed for funding, and by building additional community infrastructure that can catalyze and support other funding; and
  • Creating opportunities to designate government dollars for these efforts and generating an important incentive for all contributors to demand that payments and policy be aligned.


Health Equity Zones, and how states have invested in them, offer a blueprint for how health systems and payers can organize and align their own internal health equity strategies and resources by place. (HealthBegins now helps health plans, especially Medicaid health plans, do exactly this. Tune in August 17th, 2022 to learn more) 


Health Equity Zones in Rhode Island


The Health Equity Zone model originated in Rhode Island, and the Rhode Island Department of Health (RIDOH) currently supports 15 Health Equity Zone (HEZ) collaboratives with more than $30 million in public health funding. The issues that these collaboratives have tackled vary from addressing racism in local government and increasing civic engagement to reducing high rates of substance use and overdose and increasing access to affordable childcare. RIDOH aims to eventually spread the model across the entire state. Here’s how each zone is established:


Residents Define the Boundaries of Their Community


In an effort to incorporate equity from the ground up, zones are defined by people who live and lead in those communities. Sometimes a HEZ aligns with a specific municipality or census tract, but other times parts of several different neighborhoods may form a HEZ because the community identifies itself inside or outside of the political and municipal boundaries. The state’s only requirements are that a zone has at least 5,000 people, is contiguous, and has some sort of measurable health inequity or health disparity that the community wants to work together to resolve.


Each Community Determines Its Needs and Approach


At its core, Rhode Island’s HEZ initiative is a community empowerment model. Every zone is given a $150,000 planning grant during its first year. A community-based organization with deep roots in the community serves as a backbone agency to facilitate coordination of the work and act as a fiduciary agent. During its first year, each collaborative conducts a community needs assessment and creates an asset map. They then report back their findings to residents to ensure the findings of their assessments are truly representative of the community who will be served and to unpack the root causes of some of the issues reported. At the end of their first year, the HEZ delivers an action plan of what issue(s) they plan to address and how they plan to approach these based on the community’s existing assets. In order to move away from exploitative practices, HEZs are strongly encouraged to pay members of the community who aren’t employed by a participating organization but who help develop the HEZ’s action plan as resident ambassadors.


Health Equity Zone collaboratives are awarded an additional $150,000 per year for three to four years to enact their plans. This funding supports continued collaborative engagement and work with both state and federal agencies in leveraging funding to support both public health and non-public health community priorities and also supports the HEZ in pursuing philanthropic and private funding to advance the community action plan. In addition to providing funding, RIDOH builds capacity by deploying full-time project officers to each HEZ, hosting quarterly Learning Community collaborative sessions that are co-led by the HEZs, providing monthly mentoring sessions with the evaluators in each zone, and convening the state’s and organizational fiscal teams to build skills around grant and fiscal management at the community level.


Rhode Island Department of Health building


Partners Align Their Goals to Amplify Impact


In West Warwick—where it often took residents a full-day to reach health care and basic resources by public transit—the HEZ worked to ensure adequacy of Rhode Island Public Transit Authority bus routes and bus stops to connect residents with jobs and resources. They successfully got new bus stops added in their community and prevented further cuts to local or specialized transportation services through 2022.


The Newport HEZ conducted a racial-justice and economic inclusion audit of the city’s proposed land-use and economic development plan in its North End neighborhood. The Newport HEZ launched a project to work with residents to develop an equitable development plan for the community to address the cascading sequence of large-scale public- and private-sector development projects that threaten the North End neighborhoods with gentrification and displacement.


Best Practices for Investing in Place-Based Health Equity Work


Funding place-based health equity work to foster success requires several steps. Christopher Ausura, Co-Director of RIDOH’s Health Equity Institute, shared lessons learned from funding HEZ collaboratives in Rhode Island that health systems and payers can use when guiding their own place-based efforts.



1) Align payments and incentives to ensure that value-based payment models center equity and support collaborative, place-based efforts.


Health Equity Zones align strategic approaches and interventions implemented through multi-sector collaboratives in geographically defined communities in ways that respect the community’s expertise and empower residents to change the structures and systems that perpetuate health inequities. As health plans pursue equity, these equity-centered strategies should be structured to partner with and financially resource trusted community providers to improve outcomes downstream through direct social service care and supports for acute social determinants of health needs, through midstream integration of services across payer populations in particular geographies to manage complex health problems across provider populations, and by changes upstream at the structural and population level to ensure gains are sustained beyond a particular patient group.



2) Don’t lead with compliance.


In Rhode Island, each HEZ has a project officer focused on supporting that community’s success, not monitoring compliance. These project officers are members of the community, and many previously worked within a HEZ prior to joining the state team. They attend meetings, build relationships, and bring best practices back to RIDOH to inform work with future HEZs. It took nearly two years to fully transition to an empowerment model where compliance wasn’t driving the management of these grants, but making this shift built trust and changed RIDOH’s relationship with communities.


“We don’t need to walk in the door and threaten to take money away from people when things aren’t going right,” Ausura says. “When you do that, grantees hide what isn’t working so you don’t take their funding away.” By changing their approach, RIDOH started receiving more honest feedback on performance and outcome challenges. It also facilitated collaborative ownership of the department and communities collective performance, which led to improved performance and ultimately better outcomes.



3) Use the infrastructure created in a community to leverage other funding.Funding from RIDOH represents only a portion of funding in most of Rhode Island’s HEZs. Collaboratives use their action plans as a roadmap to solicit and secure funding for the real needs and priorities of their respective community, creating a more equitable funding portfolio aligned with the unique assets and challenges of that community. Additional funding is secured through philanthropic sources, other state and federal grants, private investments, municipal appropriations, and more. Unfortunately, many of these funding sources remain siloed and are often structured as transactional investments.


RIDOH sees its investment in the Health Equity Zone initiative as catalyst funding and looks for ways to support other sectors and funders who want to leverage an equity framework to improve outcomes. “What keeps me going with this work is that we’ve shown that you can do this,” Ausura says. “You can still maintain compliance with federal funders, state regulators, investors, the whole bit, while working together versus working in an antagonistic, top-down manner. Using an equity-centric approach is simply more effective and more efficient, and we believe this is the future of health investing.”