Christopher J. Ausura, Co-Director, Health Equity Institute, Rhode Island Department of Health
In 2015 the Rhode Island Department of Health (RIDOH) launched a project called the Health Equity Zones (HEZ) initiative, with the goal of creating a new public health approach. Rather than prioritizing specific health outcomes, Rhode Island’s HEZ initiative was designed to shift investments upstream to improve the social, environmental, and economic determinants of health by intentionally investing in community infrastructure and resident empowerment. The HEZ initiative has grown over the past seven years to become an internationally recognized model for operationalizing health equity, and during that time we have learned a lot about the role of community investments and how our approach needs to be rethought if we are truly going to invest in health equity.
The Importance of Infrastructure for Building Community Power
At its core, the HEZ initiative is a community empowerment model. Currently, every HEZ is provided with $150,000 per year that is designated as “core infrastructure” funding. The first year of work is dedicated to the development and growth of a community collaborative; the execution of a community assessment to identify the needs and assets of their respective community; adequate funding and time to deeply engage with community residents and stakeholders; and the development of a formal plan of action.
The formal plan of action is intended to provide a road map for equitable investment in the community, and the state commits to supporting these communities in advocating for the needs of their community with funders to ensure that public health and non-public health resources are invested in ways that respond to the needs of the residents and stakeholders of a community.
The sustained commitment to supporting the infrastructure of the HEZ provides stability for the collaborative partners and allows the HEZ to build momentum year over year. Momentum and sustained collaboration have led to significant shifts in community power dynamics that are beginning to drive political and social change in communities across Rhode Island.
Although we are now seeing the power of this model emerge, the journey has not been without significant changes in approach that have been essential in shaping our successes to date.
Recognizing our Role in Perpetuating Inequity
Shortly after the close of the first year of the HEZ initiative in 2016, it became clear that the vision for Health Equity Zones and the operational reality were not converging. RIDOH had developed a braided funding model to launch the initiative, largely derived from public health sources, and the action plans the HEZ had developed strongly reflected existing public health priorities and intervention strategies, not approaches to change the social, environmental, and economic conditions that drive health inequities.
The request for proposals was deliberate in calling for strategies to address these structural barriers to health. The model for collaborative development, assessment, community engagement, and prioritization were clearly designed to lift up the voice of the community, but something still was preventing these community leaders from utilizing this funding to do the transformational work that this investment was intended to catalyze.
It turned out that as a funder we had created structural barriers—such as top-down appropriations processes, siloed and transactional investments, overburdensome application and reporting requirements, underfunding infrastructure and collaboration, constantly changing funding priorities, and compliance-based oversight—that perpetuated and frequently worsened the structural inequities in the communities our investments intended to support and had eroded the community’s trust.
Intentionally Investing Builds Trust
Realizing how our institutional power was driving decisionmaking and becoming accountable for intentionally changing our approach was a pivotal shift and something that continues to drive the operational approach. We have since significantly re-worked the staffing model to shift away from compliance and oversight to a model where staff serve as liaisons between the community partners and the agency; stabilized the funding model to provide assurances that core infrastructure funding would remain available to these communities to allow for momentum building, capacity development, and longitudinal efforts to address systemic and structural barriers to health equity; focused intently on the capacity of the nonprofit sector; aligned state and federal funding with the needs of the community; and more.
How Rhode Island’s Health Equity Zone Initiative Has Built Healthier, More Resilient Communities
Based largely on this new approach, the Health Equity Zone model is building a healthy and resilient Rhode Island by investing in communities and their capacity to affect change; by honoring the expertise of those who live and work in those communities; and by challenging the systems and structures that perpetuate health inequities.
This has created safer communities; improved health outcomes; increased access to healthy, affordable foods; strengthened educational outcomes; decreased social isolation; and linked people with substance use treatment and recovery services. Notable achievements include:
- The Newport HEZ has engaged the city and residents to develop an Equitable Development Plan for the North End of Newport, fostering an inclusive vision for growth that centers equity and will support, rather than displace, current residents. Bringing an inclusive, equitable form of development has the potential to improve and repair glaring disparities by directing investment in ways that can restore the historical marginalization and underinvestment that helped produce these disparities in the first place.
- The Washington County HEZ has provided evidence-based mental health first aid and suicide prevention training to more than 1,000 police officers, clergy, teachers, parents, and staff of youth-serving organizations, and has received federal funding to partner with local hospitals, community health centers, and residents to screen all patients for depression and support health care staff to provide high-quality, timely, and evidence-based care to patients at risk for suicide.
- The Central Providence HEZ is participating in a two-year, $8 million pilot investment in place-based transformation called Central Providence Opportunities. The goal of Central Providence Opportunities is to improve economic opportunity in Central Providence through affordable housing development, wage growth, local business development, and early education supports.
- The Pawtucket Central Falls HEZ partnered with the City of Central Falls to develop Rhode Island’s first Complete and Green Streets ordinance, which is designed to ensure safe access to roadways for users of all ages and abilities and to protect the environment.
- In collaboration with multiple community and municipal partners, the Pawtucket Central Falls HEZ helped lower the childhood lead poisoning rate in Pawtucket by 44 percent.
- In response to food insecurity exacerbated by COVID-19, the HEZs delivered over 670,000 meals and provided food for nearly 13,000 residents in quarantine and isolation. Statewide rates of food insecurity have decreased 32 percent from 2014 to 2019.
- The HEZs address health care access in their communities through multiple strategies including using a mobile health van; addressing health care access and cultural competency needs of sexual and gender minorities; supporting public transportation to health care facilities; providing childcare for parents to attend medical appointments; increasing opportunities for employment with health insurance benefits; and assisting residents with enrolling in public health insurance. Statewide, the percentage of Rhode Islanders who do not seek medical care due to cost has decreased by over 42 percent from 2013 to 2020.
- Since receiving COVID-19 response funding in June 2020, the HEZs have shown their ability to have a significant impact on the communities served, distributing nearly 3 million masks, over half a million meals, fostering confidence and trust in the COVID-19 vaccine, and bringing testing and vaccination sites directly to the communities that were most impacted by COVID-19.
To learn more about Rhode Island’s Health Equity Zone initiative, visit health.ri.gov/hez.