Public Private Partnerships to Strengthen the Public Health Infrastructure

Eileen Salinsky, Program Advisor, Grantmakers In Health

Governmental public health agencies at the local, state, and federal level are indispensable allies for philanthropic organizations seeking to improve population health and advance equity. These public sector organizations represent the backbone of the nation’s public health infrastructure, responsible for “assuring the conditions in which people can be healthy.” The critical elements of this mission are described by the ten essential public health services and operationalized through the foundational public health services which identify the capabilities and program areas that all health departments should possess.

As the COVID-19 pandemic tragically demonstrated, our public health system is inadequately prepared to respond to existing and emerging health threats due to chronic underfunding, workforce erosions, outdated technology, and wavering political support. The categorical, restricted nature of most public health funding streams compounds the problem of low funding levels, leaving public health agencies with very limited flexible financing that can be used to support core capacities. Funding and legal authorities also vary across jurisdictions, resulting in significant variations in foundational capabilities, inconsistent levels of preparedness, and weak spots in the public health infrastructure.

Because of these gaps in functional capacity, some health funders report limited relationships with state and local public health authorities. Health funders, particularly those focused at the local level, are eager to identify local health departments with the ability and willingness to play a meaningful role in implementing the innovative strategies needed to create systemic change in communities.

Many health funders have been successful in establishing strong, lasting relationships with governmental public health agencies. In April 2021, Grantmakers In Health (GIH) put out a call asking foundations to self-identify if they had formed strong working relationships with local public health departments. Because we were specifically seeking to explore partnerships with local health departments, most respondents represented foundations that fund at the local or regional level. GIH conducted informal interviews with these respondents to characterize their partnerships with governmental public health agencies, assess how these relationships have evolved over time, and explore collaborative activities related to pandemic response and recovery.

This article summarizes key themes from these interviews, focusing on important lessons learned for improving partnerships with local health departments, including meeting local health departments where they are; being open to multiple types of collaborative relationships; supporting data-driven partnerships; encouraging multisector collaborations; engaging in policy analyses and advocacy to support local health departments; and committing to long-term, sustainable partnerships.

Meet Local Health Departments Where They Are

Respondents stressed that productive relationships with local health departments require foundations to be flexible and responsive to the needs of their public sector partners. In many cases, particularly when relationships are still in early stages, this may require letting local health departments take the lead in setting priorities for collaborative efforts. Several respondents noted that outreach to local health departments rooted in a “How can we help you?” orientation is typically more successful than attempts to recruit assistance for foundation-driven programs or initiatives.

Philanthropic partners need to understand the capacity and political constraints facing local health departments and have realistic expectations for the ways governmental public health agencies are able to engage in partnership activities. Because these constraints vary widely across jurisdictions, it helps if foundation leaders are knowledgeable about the local health departments in the communities they serve and gain an in-depth understanding of their funding sources, staffing levels, legal authorities, and governance models.

Many of the foundations reporting strong relationships with local health departments noted that they rely upon staff members who have prior experience serving in governmental public health agencies to act as liaisons. This experience gives philanthropic leaders credibility with public sector partners and ensures that they have an informed perspective on the capabilities and needs of public health agencies. While such experience is not essential, foundations lacking staff with a background in governmental public health may need to find alternate methods to ensure they fully understand the operational reality facing local public health officials.

Be Open to Multiple Types of Collaborative Relationships

Foundation leaders reported various types of collaborative models for partnering with local health departments. Health funders rarely pursue only one type of collaborative model, seeking instead to choose the approach the best meets the needs of a particular challenge or opportunity. Collaborative approaches can be divided into four major types of interactions:

• Direct Funding of Local Health Departments: Many respondents reported that they provide grant funds directly to local health departments in order to support high priority activities. Foundation leaders acknowledged that direct funding for government agencies raises concerns about philanthropic supplantation of government’s responsibilities to fund in the public interest. However, respondents felt that a rigid refusal to fund public sector agencies would result in missed opportunities to improve health and advance equity. Most respondents felt that direct funding to local health departments was appropriate and valuable in certain circumstances, such as when emergent risks to community health are high and public sector funding is not immediately available, when philanthropic “venture capital” can catalyze public sector innovation to improve efficiency or increase impact, and when private sector investments have the potential to leverage greater public sector funding in the future.

For example, the Connecticut Health Foundation, in partnership with Connecticut COVID-19 Charitable Connection, provided over $1.2 million to eight local health departments in the state to hire Community Health Workers to assist in COVID-19 response efforts, including contact tracing, community education, outreach to vulnerable residents, helping individuals schedule appointments for vaccination, assisting with vaccine clinics, and supporting families in quarantine. To assure equity in COVID-19 outreach and vaccine access, the foundation focused on supporting local health departments located in communities that have been hardest-hit by the pandemic. The foundation’s grantmaking was supplemented by an additional $743,500 supported through the Connecticut COVID-19 Charitable Connection, an organization formed to raise money to respond to COVID-19.

While the pandemic created an unprecedented need for direct funding of local health departments, particularly before federal funds became available, several respondents also noted long-standing grants to support local health department programs. For the last 15 years the Wyandotte Health Foundation has funded the Wyandotte County Health Department’s program to provide radiology services to the county’s indigent residents through a radiology collaborative comprised of the county safety net clinics. Seeing the need for better access to these services, the foundation encouraged the local health department to establish the program and has provided financial support since the program’s inception.

• Aligned Funding of Community Based Organizations: Rather than providing grant dollars directly to local health departments, many foundations fund community-based organizations to conduct activities designed to complement and coordinate with the efforts of governmental public health agencies. For example, in April 2021 the Foundation for a Healthy High Point funded the YWCA High Point to begin a six-month pilot program called VaxConnect to increase COVID-19 vaccinations among people who are hesitant, lack access to transportation, and are residents of two zip codes in Guilford County, North Carolina heavily impacted by the pandemic. The YWCA High Point hired three individuals as community connectors who were trained by the Guilford County Health Department. Working alongside volunteers, the connectors engage in door-to-door outreach to provide education about the COVID-19 vaccine, assistance with scheduling appointments, and support for transportation to vaccine sites. Outreach efforts are highly coordinated with the local health department to ensure canvassers can schedule vaccination appointments at the county-run clinics in real-time while engaging with residents.

After the first month, early results suggest that VaxConnect is making an impact and reducing barriers for individuals to receive the COVID-19 vaccine. Approximately 19 percent of those who were contacted at home and were unvaccinated (130 individuals) made appointments to receive the vaccine. The vaccination rate within the first focus neighborhood is approximately 37 percent, over five times the rate of surrounding areas. 

• Foundation Regranting of Public Sector Funds: A few respondents indicated that their foundations receive funds from public health agencies and generally regrant these funds to community-based organizations to provide services. Foundations are often more nimble than public sector agencies, can typically distribute funds more quickly, and may have a more nuanced understanding of community needs and stronger relationships with community members and nonprofit organizations. For example, The Health Foundation of Greater Indianapolis works in partnership with the Indiana State Department of Health and the Marion County Public Health Department on a variety of programs to treat and prevent HIV/AIDS. In addition to distributing foundation-funded grants, the foundation assists the state by administering contracts for pass-through federal resources that support projects and agencies associated with the Ryan White program. The state health department also contracted with the foundation to lead and facilitate an Ending the HIV Epidemic needs assessment and consultation process for Marion County.

• Advice and Consultation: Although collaborative partnerships often involve the sharing of financial resources, in many cases collaborative relationships also depend on the sharing of in-kind services and staff expertise. Respondents stressed the value of maintaining open, honest, and supportive communication with local public health officials to improve the effectiveness of both private and public sector activities. Health funders occupy a unique space in their communities and can often serve as a neutral broker helping public health agencies navigate controversial issues and building bridges to other community partners.

Health funders frequently play key roles on government task forces or advisory councils. For example, staff from the Marin Community Foundation participate in and facilitate the Marin County COVID-19 Community Advisory Board which provides input to guide equitable vaccine allocation and distribution. Marin Health and Human Services decided early on to center equity in its vaccine distribution strategy and convened the Community Advisory Board to ensure transparency around vaccine allocations, increase confidence in the vaccine, and solicit input to tailor communications and reduce access barriers. Building on their long-standing, trusting relationship, the county asked the foundation’s director of health and aging to facilitate the group to encourage inclusive membership and meaningful participation. Feedback from the board helped the county refine its vaccine distribution strategies, such as suggesting improvements to signage at mass vaccination sites, prompting the addition of walk-in capacity, and allowing phone registrations. In addition to assisting the county, participation in the board also informed the foundation’s grantmaking, such as revealing the need for additional engagement of faith-based organizations in vaccine outreach.

Foundations may also invite local public health officials to participate in collaborative initiatives and working groups, allowing them to share their expertise and ensuring coordination with public sector efforts. Seeking to increase awareness of the impact of adverse childhood experiences (ACEs), trauma, and toxic stress, the Winer Family Foundation launched the Charlotte Resilience Project (now called the Community Resilience Project) working collaboratively with five other foundations and the Mecklenburg County Public Health Department. A steering committee, co-chaired by the foundation president and the local public health director, included local leaders in health care, law enforcement, early education, and judicial systems. The project arranged public screenings of the documentary film Resilience and provided trainings and resources on trauma-informed approaches and resilience-building techniques. The local health department was able to harness the project’s momentum to deepen engagement and expand training opportunities through the newly formed ReCAST Mecklenburg initiative, fueled by a $5 million federal grant.

Informal means of ongoing communication are also important for maintaining productive relationships. For the last several years, staff from The Health Trust in San Jose, California have convened quarterly lunches with staff from the Santa Clara County Public Health Department. These informal meetings allow the partners to provide regular updates on their respective activities, promote collaborative problem solving, and build trust to facilitate course corrections, and identify additional opportunities for joint efforts.

The importance and influence of these informal relationships should not be underestimated. Strong bonds of trust, candor, and mutual support between philanthropic organizations and public health agencies can prove pivotal in decisionmaking. Several respondents noted that local public health departments knew their philanthropic partners “had their backs” and could be counted on to advocate on their behalf. For example, one foundation leader was able to communicate with state officials to successfully endorse the local health department’s request to have a COVID-19 testing site located within their community.

Support Data-Driven Partnerships

The disease surveillance and vital statistic reporting responsibilities of local health departments offer fertile opportunities for partnerships with philanthropic organizations. Several respondents emphasized the value of data-driven partnerships that can open the doors for broader forms of collaboration. Community Health Assessments (CHAs), which local public health departments are required to conduct in order to receive accreditation through the Public Health Accreditation Board, identify key health needs and community resources through systematic, comprehensive data collection and analysis. These CHAs are often used to develop Community Health Improvement Plans (CHIPs) which set priorities and target resources to address the health problems identified.

A number of foundations provide funding to governmental public health agencies to support Community Health Assessments and Community Health Improvement Plans. The Montana Healthcare Foundation’s very first grant in 2015 provided $1.3 million to the Montana Department of Public Health and Human Services which supported 34 county and tribal public health departments to convene community partners, identify key health challenges, and develop collaborative plans to address them.

Similarly, in 2017 the Legacy Foundation of Southeast Arizona funded a collaborative Community Health Assessment and subsequently a Community Health Improvement Plan in Cochise County. Led by Cochise Health and Social Services in partnership with the foundation and area hospitals, the effort brought together residents and community leaders, nonprofit and social service agencies, governmental institutions, and federally qualified community health centers to identify, prioritize, and address the major issues threatening the health and well-being of Cochise County residents. The foundation believed that a community scan of unmet needs was essential to advancing its own mission and recognized that such a scan would be more impactful if it also created shared priorities for the various organizations in the county responsible for improving population health.

The Horizon Foundation conducts the Howard County Health Assessment Survey in collaboration with the Howard County Health Department, Howard County Hospital, and the Columbia Association. Designed to harmonize with the Behavioral Risk Factor Surveillance System (BRFSS), the survey was developed to assess health-related behaviors and risk factors among the adult population of Howard County, Maryland. Partners in the survey effort each contribute funding and have established a Memorandum of Understanding to delineate each organization’s roles, responsibilities, and financial obligations. In addition to providing an in-depth assessment of community health needs, the data-driven process provides an effective platform for establishing shared priorities and ensuring well-integrated, collaborative response activities. The partners work together to analyze survey results and develop coordinated strategies to address priority health needs with each organization pursuing approaches that align with their respective missions and competencies.

Some health funders help local health departments make their data more accessible and useful to the public. For example, The Otho S. A. Sprague Memorial Institute funds the Chicago Health Atlas which aggregates municipal, state, and federal data along with information from Chicago-area hospitals and nonprofits on useful open-source maps that easily explain health and wellness patterns in Chicago’s 77 community areas. Developed by the Chicago Department of Public Health, the Population Health Analytics, Metrics and Evaluation Center at University of Illinois Chicago, and Metopio, the Chicago Health Atlas tags much of its data to a census tract, ZIP code, county-level, or community areas, allowing users to look at data on a granular level to help tailor policies and programs to a specific area’s health needs. The Atlas is meant to be an evolving tool with new partnerships providing additional data and insights on health within Chicago. One such effort is conducted by MAPSCorps which deploys teams of community-based youth to collect, update, and analyze information about the neighborhoods in which they live.

Encourage Multisector Collaborations

Multisector collaboratives offer public health agencies a powerful forum for identifying and adopting innovative approaches and philanthropic support can be critical in establishing and maintaining these impactful efforts. As described by the BUILD Health Challenge, no single organization or sector can successfully address the intersecting factors that influence the social determinants of health, such as early childhood development, employment opportunities, food availability, air and water quality, transportation, educational attainment, public safety, and housing. Multisector collaboratives bring together multiple stakeholders with a shared commitment to improving health and advancing equity. These collaboratives allow public health departments to engage in issues and strategies that transcend their more traditional duties.

The Blue Shield of California Foundation supports the Bay Area Regional Health Inequities Initiative (BARHII) which is a coalition of ten public health departments and over 200 community-based partner organizations. BARHII develops programs to help vulnerable Bay Area residents, builds the capacity of organizations to develop equity-based solutions, and influences policy that improves the quality of life for millions in the Bay Area. After identifying housing as a critical public health issue, BARHII’s members led a regional response to preserve existing affordable housing, protect tenants at risk of displacement, and produce additional affordable housing. Through this effort Kaiser Permanente and the Solano County Public Health Department were also able to lend a health voice to advocacy efforts supporting an eviction moratorium in Vallejo, CA in response to COVID-19.

Engage in Policy Analyses and Advocacy to Support Local Health Departments

Significant improvements in the public health infrastructure ultimately depend on policy change to increase funding, modernize operations, and optimize legal authorities and governance structures. A number of national foundations, including the de Beaumont Foundation, the Robert Wood Johnson Foundation, the W.K. Kellogg Foundation, and the Kresge Foundation have made significant, long term investments in policy-oriented work to strengthen the public health infrastructure. These efforts include annual assessments of states’ readiness to respond to public health emergencies and policy recommendations to respond to gaps in preparedness, longitudinal surveys of the public health workforce to track interests and needs, identifying strategic skills critical to public health workforce development, building public health departments’ capacity to advance equity, transforming public health data systems, leveraging public health laws and legal authorities, and advocacy to advance policy change.

While national efforts to inform and influence policy related to the public health infrastructure are more highly visible, a number of local funders also invest in policy research and advocacy to strengthen governmental public health. For example, the MetroWest Health Foundation has contracted with the Northeastern University Public Evaluation Lab to lead a comprehensive evaluation project to understand and improve upon the current public health infrastructure in the MetroWest area of Massachusetts. Unlike most states, in Massachusetts local public health departments are organized at the municipal, rather than county or district level, resulting in fragmentation of services across 351 separate cities and towns. The Northeastern research team will be interviewing leaders in municipal departments and human service organizations within the MetroWest region, across 25 communities, to invite their perspectives on the benefits and challenges of collaborating on public health initiatives, such as through the creation of shared service agreements. The aim of this important work is to help build and strengthen existing public health partnerships as well as develop recommendations for the MetroWest Health foundation and community stakeholders.

At the state level, the Montana Healthcare Foundation commissioned the Creating a Vision for a Healthier Montana study to bring together interested stakeholders and determine practical, collaborative ways to strengthen the public health system. The study found that Montana’s 58 county and tribal public health departments face limited resources to address critical health challenges and recommended: (1) development of a nonprofit public institute to support the public health system, particularly at the county and tribal levels, (2) realignment of the state’s nonprofit public health associations, and (3) strengthening relationships with local elected officials, their associations, and critical health leadership groups. With development efforts accelerated by the pandemic, the Montana Public Health Institute was incorporated as a nonprofit in April 2020 and the foundation provided a $1.85 million, five-year grant to launch the organization.

Commit to Long-term, Sustainable Partnerships

Most respondents reported long-standing relationships with their local health departments that pre-date the pandemic and have strengthened and evolved over time. For some, these relationships have been strong since the foundation’s inception; for others, relationships with local health departments had to be nurtured and prioritized in order to cultivate trust and effective communications.

A few respondents shared that local health officials were not initially receptive to partnership opportunities. These foundations devoted months, or even years, to building relationships with governmental public agencies. Sometimes this meant waiting for a change in leadership to find a local health director more open to collaborative efforts. Some respondents volunteered to participate in search committees to help identify local health official candidates who would bring a partnership-oriented vision for community health.

Although relationship-building efforts understandably prioritize the local public health director, several respondents stressed the importance of establishing relationships with multiple people working in local health departments, such as epidemiologists and maternal and child health directors. These programmatic relationships provide a deeper understanding of local health department operations and ensure continuity of work in the event of leadership transitions.

Unprecedented turnover among local health officials due to an aging workforce and pandemic-related stressors and harassment underscores the wisdom of establishing multiple lines of communication with health department partners. An ongoing analysis by the AP and KHN found at least 248 leaders of state and local health departments have resigned, retired, or were fired between April 1, 2020, and March 31, 2021, with nearly 1 in 6 Americans losing a local public health leader during the pandemic.

Seize the Current Moment

This is a time of both promise and peril for the public health infrastructure and philanthropic support is needed now more than ever. Public health officials across the country are under enormous pressure to address the greatest public health crisis of a generation while continuing their routine responsibilities. The pandemic has raised public awareness of the role governmental public health agencies play in keeping communities healthy and resulted in a fresh infusion of resources for COVID response and recovery. However, COVID-19 has also unleashed a backlash, with public health officials facing criticism, threats, and attacks and policymakers in at least 24 states considering bills that would limit governmental public health authorities.

The current moment represents a fleeting window of opportunity to ensure a stronger public health system. As the roles of and resources for public health agencies are being reconsidered, health funders must also engage in self-reflection. How strong is your organization’s relationship with local health departments in the communities you serve? Do you view governmental public health as an essential partner? How can you best increase and improve support for state and local public health departments?  What types of investments are most likely to yield transformative change? As the future of public health hangs in the balance, philanthropic organizations must renew their commitment to governmental public health agencies and reimagine strategies for strengthening these partnerships.