By Stephanie Bultema
Have you ever needed health care, sought it out, and been left feeling like the organizations that are supposed to help you are just there to spin the wheels of bureaucracy and insurance companies? If you answered yes, it is probably no surprise to learn that you are not alone.
Health care systems in the United States are notoriously fragmented and riddled with conflicting interests. While health insurance companies, pharmaceutical companies, lobbyists, and business priorities have great influence over health care systems, the communities and individual patients that health care systems are intended to serve have little power over how these systems function. When you broaden the scope beyond health care systems to look at community health systems things get even more complicated.
Community health systems are the complex networks of organizations, services, resources, and policies that contribute to individual and population health. In addition to traditional health care organizations like hospitals and health clinics, community health systems include organizations that focus on education, housing, transportation, built environment, economic development, public safety, and so much more. This broad focus stems from the social drivers of health (also known as social determinants of health), which recognize that where you live, the type of work you do, and what your neighborhood is like, are all factors that contribute to your ability to be healthy and well. These social drivers have a greater impact on health than medical care, with estimates showing that around 50 percent of a person’s health is determined by these social drivers of health.1
Over the last decade, federal and state policies have prioritized strengthening community health systems using approaches that center community residents and community-based organizations in transformation efforts. One example is the Accountable Communities of/for Health (ACH) model, which has been guiding health system transformation efforts in several states since 2015. ACHs are “community-based partnerships formed across sectors such as health care, housing, social services, public health, employment training and economic development to focus on a shared vision and responsibility for the health of the community.”2 These partnerships received initial funding from government agencies and private foundations, which supported dedicated staff time to focus on ACH work.
The growing interest in leveraging community-based partnerships such as ACHs to lead community health system transformation efforts demonstrates a need to understand effective strategies for how to center communities in these partnerships. We know from decades of research that cross-boundary partnerships, systems transformation, and authentic community inclusion are all extremely challenging endeavors.3 Since ACHs and similar partnerships are simultaneously navigating multiple complex processes to generate long-term collective outcomes such as improved health equity, it is critical that they leverage evidence-based strategies to increase their chances of success. The following sections highlight key lessons from 2020–2023 research on centering communities in health system transformation efforts.
Research done by the Population Health Innovation Lab (PHIL) at the Public Health Institute explored how ACHs brought people and organizations together across boundaries to improve community health and well-being.4 The research team worked with 22 ACHs in Washington and California to learn what works for who, when, why, and where when seeking to transform community health systems. After three years of mixed-methods research, we learned that including and sharing power with community members and systemically marginalized groups is an indispensable part of a successful ACH.
The natural question that follows is: How can community health system transformation efforts like ACHs effectively center communities and community residents in their efforts? We learned that the following strategies for community inclusion had the greatest positive influence when working to create systems change, improve equity, and sustain collaboration:
- Include many different perspectives.
- Share decision making power.
- Be intentional.
Include many different perspectives. The most effective ACHs dedicated time and resources to including diverse people and organizations in community health system transformation efforts.
These communities:
- Hosted cross-boundary meetings that brought people together across communities, sectors, and organization types.
- Consulted neighboring Tribal Nations.
- Gathered input from many people through community convenings, listening sessions, surveys, and focus groups.
- Used community input to guide decision-making.
Figure 1. The Community Speaks
An ACH serving an urban county worked with a local community-based organization to learn about the health-related needs and priorities of community residents through surveys, focus groups, and community events.
Share decision making power. The most effective ACHs did not just include diverse perspectives in the work, they went a step further by creating shared decision making across different groups that would not normally work together, like hospitals, health clinics, schools, nonprofit organizations, local governments, and Tribal Nations. These communities:
- Included systemically marginalized and underserved people and groups when defining the problem to be solved through the ACH, developing a shared vision, deciding what to do and how to do it, and when moving those plans to action.
- Used structured approaches to include diverse perspectives in decision making, such as participatory budgeting, designating board seats for specific sectors or groups, and working with community advisory groups (e.g., Community Voices Council, Tribal Partnership Leadership Council).
Figure 2. Shared Governance and Decision-Making
Better Health Together (BHT) serves multiple rural, suburban, and urban counties and the Colville Confederated Tribe Reservation, Spokane Tribe of Indians Reservation, and the Kalispel Tribe of Indians Reservation. BHT shared decision-making power with community residents through formal governance structures. They established technical councils that were co-chaired by a community member and a board member. The Community Voices Council focused on setting health equity goals and integrating community voices in decision making.
Be intentional. The most effective ACHs were intentional about how they included diverse perspectives in the collaborative work and facilitated power sharing. They did not leave these things to chance, but rather built them into how they did business. In addition to using structured approaches to including diverse perspectives in decision making, these communities:
- Made it easy for community residents to participate in collaborative activities by ensuring meetings could be joined by video or phone, rotating meeting or event locations, holding meetings outside of normal working hours, and communicating in multiple languages.
- Shared information and increased transparency of decision making by holding open board meetings, publishing detailed project plans, and making meeting minutes publicly available.
- Made sure everyone benefited from participating in system transformation efforts, for example through new connections, resources, funding, training/education, or helping participants to achieve their own goals.
Figure 3. Community Engagement Plan
North Sound ACH serves multiple tribal reservations and counties, including rural, suburban, and urban communities. North Sound ACH created an intentional and multi-faceted plan for engaging community residents in health system transformation efforts. In addition to prioritizing community input, the plan outlined how community residents would be included in ACH governance and programming, and how they could benefit through training, support, and accommodations.
The ACHs with the highest approval ratings from their participants were those where communities took care to include many different perspectives, share decision-making power with systemically marginalized and underserved groups, and intentionally integrate these practices into the collaborative work. As towns, cities, counties, regions, and states seek to improve the systems that contribute to community health and well-being, they can draw on lessons learned from the approaches used by ACHs to center communities in health system transformation efforts.
While we are still a long way from having fully effective and efficient community health systems in place, the recent efforts to meaningfully include community voices and share decision making power with systemically marginalized and underserved groups are an important step toward improving the systems that support (or hinder) health and well-being in the United States. ACHs demonstrate one approach to making all the diverse organizations that contribute to individual and community health and well-being more inclusive, accountable, and responsive to citizens.
To learn more about ACHs, how they integrate community voices into health system transformation efforts, and how they have influenced community health outcomes, head to the Aligning Systems for Health with ACHs web page to learn about PHIL’s research findings or read the related dissertation, “Linking Collaboration Dynamics to Outcomes in Collaborative Governance.”5
A note of gratitude: In 2020, I had the opportunity to partner with the Population Health Innovation Lab (PHIL) at the Public Health Institute to conduct research for my dissertation, “Linking Collaboration Dynamics and Outcomes in Collaborative Governance.” The National Civic League helped make this research possible when they made me a Pforzheimer-National Civic League Fellow in 2019. This fellowship helped me finalize my research proposal and build support for the research project, which led to a partnership with PHIL and additional support from the Robert Wood Johnson Foundation. Thank you, National Civic League, for your investment in my academic journey and the research described in this article.
Stephanie Bultema, PhD, works as Director of MERLIN: Monitoring, Evaluation, Research, and Learning Innovations at the Public Health Institute’s Population Health Innovation Lab (PHIL), where she directs PHIL’s scientific vision and strategy. Her research and practice focus on systems change for improved population health, well-being, and equity.
