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Strategies fr Buildig CmmuityPublic Health Parterships
Lessons Learned from the Program office of t
PartnershiP for the PubLics heaLth initiative
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Partnership for the Publics Health would like to acknowledge those who
contributed to the writing and publication of this document.
Editor: Susan Wels
Authors: Partnership for the Publics Health
Maria Casey, Bob Prentice, Julie Williamson, Kathryn Boyle
Center for Community Health and Evaluation
(contributed Creating an Evaluation Community)
Clarissa Hsu
Bill Beery
Reviewers: The California Endowment
Marion Standish
George Flores
We would also like to thank members of the PPH Advisory Board and
the Evaluation Advisory Subcommittee, who provided their expertise,
guidance and innovative thinking in shaping the design, implementation
and evaluation of the initiative.
Advisory Board
America Bracho, Bob Brownstein, Zoe Clayson, Arthur Chen, Benjamin
Cuellar, Maryam Far, Lupe Fierro, Tessie Guillermo, James Johnson, Joyce
Lashof (Chair), Ortensia Lopez, Tom McGuiness, Cle Moore, Miguel Perez,
Rita Scardaci, Mildred Thompson, Ellen Wu, Rosa Martha Zarate Macias,
Mickey Richie, Joseph P. Hafey, Carmen R. Nevarez, Marion Standish
Evaluation Advisory Subcommittee
Zoe Cardoza Clayson (Chair), Judy Chynoweth, Eugenia Eng, Steve
Fawcett, Vincent Francisco, Robert Goodman, Marshall Kreuter, Ortensia
Lopez, Chuck McKetney, Bobby Milstein, Meredith Minkler, Edith Parker,
Sarah E. Samuels, Emma Sanchez, Rita Scardaci, Curtiss Takada-Rooks,Celestine Walker, Jim Wiley, Sandra Witt
Published by Partnership for the Publics Health (Program Ofce) with
support from The California Endowment.
December 2007
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buildingPublichealthPartnershiPs
At the core o the PPH initiative was the relationship
between public health departments and communityresidents. A key mission o PPH was to invest in building
the partnerships between health departments and local
communitiesencouraging them to work together, agree
on community health priorities and jointly develop
strategies to address them.
Forming these partnerships was difcult. In many cases,
partners had to overcome legacies o mistrust between
communities and government agencies as well as power
dierentials that had characterized their interactions in thepast. In addition, communities and public health
departments oten had little understanding and appreciation
o their respective resources, roles and responsibilities.
Despite these challenges, many strong partnerships emerged
during the course o the PPH initiative. In the process, the
initiative was able to identiy organizational models, success
actors and strategies that enabled public health
departments to work productively with local communities.
leadershiPandresidentengagement
Strong leadership was the crucial variable that enabled some
public health departments to go beyond traditional practice
and institutionalize CBPH practices. According to a report
by the Center or Community Health & Evaluation, strong
agency leaders were able to persuasively articulate the
benets o working with the community and inuence
organizational culture and decision making.
Resident involvement was another critical element o
success. Neighborhood residents bring rst-hand experience
and skills, as well as knowledge o community needs,
priorities and resources. Tey are also committed to
improving the health o their amilies and community and
can motivate riends and neighbors to participate actively in
the process.
Productive, sustained resident engagement, however, is
challenging to achieve. I residents are not paid or provided
incentives to be involved, it can be difcult to maintain their
interest. It is also helpul or them to experience wins early
on. In community groups as well as public health
departments, successul resident engagement took committed
leadership that institutionalized resident engagement as a
ormal, budgeted priority.
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toolsandresources
A key strategy or designing and administering the initiative
was establishing a Program Ofce. It provided inrastructureand centralized, eective systems or grants management,
progress assessment/mid-course corrections, communications,
technical assistance coordination, evaluation oversight and
dissemination o lessons learned, and it acilitated the
clarication o goals as the initiative evolved.
A key unction o the Program Ofce was the development
o technical assistance resources to help PPH partners build
capacities including undraising, board development,
cultural competence, language access, policy and mediaadvocacy skills and an understanding o the broad
determinants o health. Highly successul tools and
strategies included a local coach model, a peer-learning
network, exible support tailored to meet the needs o each
grantee and collaborative sel-assessment to identiy training
needs. Building on its experience with the PPH initiative,
the PPH Program Ofce proved instrumental to Te
Endowment in the launch and implementation o a second
multi-site, our-year program, Healthy Eating, Active
Communities (HEAC) in 2004.
ParticiPatoryevaluation
In choosing to use a participatory approach to evaluation,
the Partnership or the Publics Health initiative made a
noteworthy and difcult commitment to power-sharing and
openness. When participatory principles are applied to a
large project like PPH, a great deal o adaptation and
innovation is needed to coordinate even limited stakeholder
participation in the evaluation process.
Te size and complexity o the initiative called or a
multilevel evaluation design that acilitated communication
and connection among all key stakeholders. Te team
included local evaluators who were chosen by the local
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collaborative partners and then worked closely with the local
partnerships to monitor and document progress and support
development o local evaluation capacity. Balancing the needs
o all stakeholders, especially those o the grantees versus theunder, involved a great deal o negotiation and compromise.
In the end, excellent tools and processes were developed,
including a participatory progress assessment process and
modied approach to the case study method that combined
qualitative description with quantitative inormation and
standardized reporting.
Policyandsystemschanges
Community health improvement is sustained through
policy and systems changes. Tese eorts, during the PPH
initiative, were most successul at the local level. PPH
partnerships were able to identiy and address community
health issues including broad determinants o health,
ranging rom access to care, youth development, nutrition
and physical activity to environment, violence, sanitation,
trafc saety, housing and transportation.
Te challenges o making statewide policy and system
changes, however, were extensive. Health departments, to
begin with, have limited exibility to make signicant
changes in programming and organizational structures. In
order or internal public health inrastructure changes to
take place, policy changes must include specic unding to
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support community-based work, reorganization o public
health systems to support CBPH and incorporation o
CBPH principles into academic programs to prepare the
uture public health workorce.
PPH advocated extensively or these changes on a statewide
level. However, advocacy or local public health
departments in Caliornia has concentrated almost
exclusively on strengthening capacity or inectious disease
control, which has eroded dangerously over the past ew
decades. As a result, some viewed the suggestion that public
health ought to have a broader visioninvolving
partnerships with communities and other public and
private agenciesas an unaordable add-on to an already
overburdened system.
Secondly, the inusion o ederal unds and short planning
timelines or bioterrorism and emergency preparedness
monopolized the agenda o public health leadership
throughout the state. Te terrorist attacks o September 11,
2001, the economic downturn in the state, the diuse
nature o public health in Caliornia and the change in
political leadership also posed major obstacles to successul
statewide policy and systems changes.
Consequently, PPH did not achieve as much as hoped in its
eorts to promote changes in statewide public health policy.
Nevertheless, the initiative did help lay important
groundwork or community-based public health in
Caliornia. PPH helped create a common CBPH
ramework and language. It also nurtured a growing cadre
o powerul, eective, articulate public health and
community leaders with successul experience in
community-based public health. In addition, the initiatives
ocus on capacity building and partnership development
helped create a deeper understanding o what is needed to
sustain this work beyond an initiatives unding period.
newstatewidefocus
oncollaboration
Since the end o the initiative, the public health policy
environment in Caliornia has changed signicantly,
moving toward a new ocus on collaborative approaches or
addressing the social and environmental determinants o
chronic disease. Although bioterrorism-preparedness eorts
drove legislation creating a new Department o Public
Health, the department, once created, as well as the
organizations that promoted it have embraced a larger
vision or its mandate, given the growing acknowledgment
o obesity as a serious health risk.
In addition, many local health departments, in spite o
unding and organizational challenges, have been
developing strategies to conront the challenges o chronic
disease.1 As a result o these combined orces, there is
considerably less riction today over the priorities or public
health in Caliornia, and there are many promising
examples o agencies and organizations working together.
It is air to say that the Partnership or the Publics Health
served as an important catalyst or these changes, ostering
capacity in local health departments and building statewide
momentum or community-based approaches to public
health. Te lessons documented in this report can help
build the evidence base and strategies or a community-
based public health structure in Caliornia and inorm
similar eorts nationally.
1 See, or example, Prentice B, Flores G, Local health departments and the challenge o chronic disease: lessons rom Caliornia, Prev Chronic Dis[serial online], Jan.,2007 (http://www.cdc.gov/pcd/issues/2007/jan/07_0081)
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For more than a century, public health has made communities healthier places to
live by reducing illness and death associated with inectious diseases. Tis ocus
has resulted in the improved saety o ood and water, the control o inectious
diseases, reductions in vaccine-preventable illnesses and lower rates o maternal
and inant mortality.
In recent decades, however, public health has had to expand its ocus to the risk
actors associated with the growing burden o chronic disease. obacco use, poor
diet and lack o activity, or example, account or two-thirds o premature deaths
associated with chronic disease.2 Changing the social and physical environments
that directly or indirectly magniy those risk actors has become an important
ocus o contemporary public health practice.
According to the IOMs 2002 report Te Future of the Publics Health in the 21st
Century,3 the new model o public health entails a ocus on population health,
including multiple determinants o health; the strengthening o the public health
inrastructure; and the creation o partnerships and accountability systems. Unde
this new model, public health agencies must continue to assert a strong
leadership role in protecting the publics health, but they cannot do it alone.
Instead, they must team with others, including local residents, to address the
broad range o actors that have the greatest impact on community health.
Tis collaborative approachcommunity-based public health (CBPH)is an
ambitious undertaking that has grown in importance and visibility as public health
has improved data collection methods and understood the genesis o disease, risk
actors and social determinants. Some o the great public health successes in recent
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ImplEmEntIng CommunIty-BaSEd puBlIC HEaltH In CalIfornIa
2 Mokdad Ah, Marks JS, Stroup DF, Gerberding, JL,Actual Causes of Premature Death in the United States, 2000. [Published erratum in: JAMA 2005: 293(3):2034, 298]
3Te Future of the Publics Health in the 21st Century, November 2002: Institute o Medicine.
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yearsreductions in tobacco use and its associated diseases,
as well as the passage o seat belt and helmet lawsinvolved
public health agencies, organized communities, health care
providers, researchers, schools, elected ofcials, advocacy
organizations and media, among others. Tese alliances are
what the ederal Centers or Disease Control and Prevention
and other national public health organizations have called
public health systems. Tey are increasingly common
practice in public health campaigns, such as those that aim
to reduce the rates and health risks o obesity. For public
health agencies to partner successully, however, they need
the skills and capacity to work eectively with communities,
standards or accountability and new and more exibleresources to achieve their goals.
cbPhincalifornia
In Caliornia, state government has been slow to
demonstrate strong leadership in implementing
community-based public health. CBPH opportunities in
Caliornia have emerged as a result o strong local public
health leadership, successul experience in tobacco cessation
and a growing understanding o health disparities. Localpublic health leadership has begun to develop rameworks
(e.g. the Spectrum o Prevention) that emphasize
partnerships and policy and successul community-public
health activities. Local innovation ueled by public health
leaderswith limited, i any, resources and creative
nancinghas provided the spark or a broader and more
deliberate approach to CBPH.
Tis emerging body o work in Caliornia has been
complemented by national eortssuch as the W.K. KelloggFoundations CBPH initiative and the Robert Wood Johnson
and Kellogg Foundations urning Point initiativeto
transorm public health. Tese oundations saw these eorts
as an opportunity to address health disparities and other
issues and developed a grantmaking program to scale up local
innovations and stimulate policy development and
leadership. It was hoped that ultimately the success o these
eorts would lead to structural changes at the state level in
public health unding, accountability and practice.
In 1999, Te Caliornia Endowment awarded $37 million
to the Public Health Institute (PHI) to plan and implement
the Partnership or the Publics Health (PPH). Tis six-year
grant-making initiative pioneered eorts to build partnerships
between communities and public health agencies in Caliornia.
By establishing 39 local partnerships, encompassing 14
public health departments and 39 community groups
throughout Caliornia, PPH aimed to gain large-scale
CBPH experience and identiy actors, rom capacity issues
to policy and systems changes, that enabled public health
agencies and communities to partner successully.
According to Marion Standish, Director o Te
Endowments Disparities in Health program, Te
Endowment recognized that public health is the only
governmental entity charged with protecting the publics
health, that it controls substantial resources and that it
needed to modernize in order to protect the public rom the
health threats o the twenty-rst century. We needed to
meaningully engage public health systematically, she said,
i we ever hope to address the social determinants o health
and sustain long-term CBPH eorts in Caliornia.
With PPH, Te Endowment sought to develop a large
enough cohort o community-based public health
partnerships to inuence state and national public health
policy and unding. It also aimed to develop experience and
evidence o CBPH practice that would build momentum
within the eld and potentially inuence policy statewide.
Te PPH initiative began to create a roadmap or how
communities and public health departments can work
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together to reduce health disparities and improve the health
and well-being o diverse communities.
Several actors set PPH apart rom other health initiatives.First, PPH ocused on building the partnering capacity o
public health departments and community-based
organizations and consequently did not prescribe a content
area or them to ocus on. Instead, community
organizations and health departments, on their own and in
partnership, dened these issues. PPH, moreover, provided
separate unding to health departments and community
organizations in order to minimize the power imbalances
that can occur between community groups and large
agencies and institutions. Community collaborative groups
held more power in their role as partners because they were
able to come to the table with their own unding.
PPH also diered rom other health initiatives in that it was
place-based, ocusing on the geographic communities where
people lived; it was resident-driven; it worked with health
departments o varying sizes; it was potentially large enough
to create momentum or statewide change; and it reected
tremendous ethnic and geographic diversity.
successesandchallenges
PPH partnerships made signicant gains in developing
advocacy skills, policy awareness and new community
leaders throughout the state. Local CBPH eorts varied
greatly. While many partnerships addressed issues around
access to care, they also addressed environmental actors like
opportunities or healthy nutrition and physical activity and
the broader determinants o health including housing,
transportation, access to jobs and sanitation. Most
partnerships were able to achieve at least one signicant
policy change in the community that directly supported
their goals or improving health.
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Many PPH partners were inspired by the potential o
CBPH. Nevertheless, the challengesespecially in such a
large-scale projectwere extensive. Health departments, to
begin with, have limited exibility to make signicant
changes in programming and organizational structures.
Nevertheless, the PPH experience identied actors that
positioned health departments to make changes in support
o a sustained, community-based ocus.
Secondly, PPHs theory o action lacked specic, statewide
policy goals, such as pressing or an ofce o community
health in Sacramento that would capture PPH eorts and
disseminate the lessons rom these eorts more widely.
Instead, policy goals were expected to originate in local
partnerships. As a result, the initiative spent a great deal o
time trying to dene and address its statewide objectives.
Additionally, PPH expected that existing public health
structures in the state would help develop the initiatives
policy goals, but those constituencies never partnered with
PPH on policy eorts. In hindsight, it would have been
helpul or the initiative to set preliminary policy goals at
the outset that would have later been inused by community
priorities and experience.
iming also proved to be an issue. Te terrorist attacks o
September 11, 2001, occurred during the course o the
initiative. In the wake o these events, the new ocus on
bioterrorism derailed eorts to expand the capacity o the
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states public health system to address the socioeconomic
and environmental actors that aect community health.
Te economic downturn in the state, the diuse nature o
public health in Caliornia, and the change in political
leadership also posed major obstacles to successul statewidepolicy and systems changes.
Caliornia, moreover, lacked strong state leadership on key
public health issues such as health disparities. It also lacked
a plan or public health improvement, as well as processes
or assessing statewide public health capacity, creating
perormance standards and accrediting local public health
departments. Prospects or collective leadership were oten
hindered by intransigent, antagonistic relations among key
statewide public health organizations.
momentumforchange
Despite these challenges, PPH nurtured a growing cadre o
powerul, eective, articulate public health and community
leaders with successul experience in community-based
public health. When asked whether they would continue
their CBPH work ater PPH unding ended, many health
department sta stated their ongoing commitment to the
collaborative model. Tey also urged creation o a largermovement, a critical mass o local health departments
dedicated to advancing CBPH.
PPh w pl l y
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Te PPH experience also suggests uture unding
approaches. Since many public health practitioners have
little or no experience working with communities or
understanding o the broader determinants o health,
unders could provide critical support by introducingCBPH training into schools o public health throughout
the state. Foundations might also help develop agreed-upon
standards or public health engagement with communities.
In addition, they could und leadership development or
public health practitioners who understand the importance
o CBPH and are striving to practice it. By doing so,
oundations could expose these proessionals to best
practices, evidence-building strategies and opportunities to
voice key issues and priorities in community health,
establishing a unied voice or CBPH that could set and act
on a policy agenda.
Te successes and challenges o the 14 Caliornia public
health jurisdictions that were part o the PPH initiative
oer many valuable lessons or unders. Tose lessons,
documented in this report, can help build the evidence base
and strategies or a community-based public health
structure in Caliornia and inorm similar eorts nationally.
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thePPhProgramoffice
A key strategy or designing and administering the initiative was establishing a
Program Ofce. A savvy team o proessionals with a broad range o skills and
experience was assembled by the Public Health Institute to manage the initiative
and support the development o local partnerships and their community health
improvement eorts.
Te Program Ofce team ocused on being responsive to the needs o grantees
and the oundation to achieve initiative goals. Te ofce provided inrastructure
and centralized, eective systems or grants management, progress assessment/mid-
course corrections, communications, technical assistance coordination, evaluation
oversight and dissemination o lessons learned, and it acilitated the clarication
o goals as the initiative evolved.
A key unction o the program ofce was the development o technical assistanceresources to help PPH partners build capacities including undraising, board
development, cultural competence, language access, policy and media advocacy
skills and an understanding o the broad determinants o health. Highly successu
tools and strategies included a local coach model, a peer-learning network, exible
support tailored to meet the needs o each grantee and collaborative sel-assessment
to identiy training needs.
PPH can be touted as a model or the organization and management o large-
scale, multi-site, community-based initiatives. Building on its experience with the
PPH initiative, the PPH Program Ofce proved instrumental to Te Endowmenin the launch and implementation o a second multi-site, our-year program,
Healthy Eating, Active Communities (HEAC) in 2004.
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technicalsuPPortstrategies
Lcal caches. o help the new PPH partnerships
achieve their rst taskdeveloping a joint, our-yearstrategic planPPH used a local coach model. Te coach,
a local consultant with high skill levels in strategic planning
and group dynamics, acilitated the joint work o each
partnership and helped them assess community health
needs, analyze results, come to agreement on priorities and
work cooperatively to develop strategies or achieving these
goals. Te model proved very useul given partners wide
skill variation and the relatively short, 10-month time rame
partners had to complete their plan. Local coaches were
available to each partnership or 10 to 15 hours per week.
Ater the rst year, more than 80 percent o the partnerships
used their own resources to continue the involvement o
their local coaches.
Peer learig. Peer learning was also used whenever
possible to support creative problem solving across sites.
Funds, or example, were made available specically or
grantees to travel to other PPH sites to share strategies and
lessons. PPH also sponsored annual conerences that
allowed grantees to learn rom each others challenges and
successes. Other peer learning activities included grantee-led
training sessions and conerence calls that tapped into the
skills that grantees brought to PPH or were learning
through the PPH eorts in their communities.
Pl f exible fudig. Rather than trying to
address all needs or support rom the central program
ofce, PPH made a pool o exible unds available to
groups or trainers or consultants and to develop
individualized trainings. Each grantee could access up to
$5,000 or individualized, tailored trainings.
Cllabrative self assessmet. Although many
community health improvement eorts rely on collabratives
to achieve policy and systems changes, relatively littleattention is paid to the actors that create highly eective
collaboratives. PPH used a tool developed by the Center or
Collaborative Planning called Perecting Partnerships: Sel-
Assessments or Strong Organizations and Healthy Partnerships.
Tis program incorporated a collaborative sel-assessment
tool, along with a group process to identiy key capacity
issues and how to strengthen them. Te assessment tool
ocused on ve core capacity areas: shared vision,
inclusiveness and quality o participation, communication,
acilitative leadership and shared decision-making.
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3 The lcal cach mdel prvedvery useful.
According to a study by the Group Health Community
Foundation, partners valued local coaches or providing
exible, locally based technical assistance and serving as
neutral acilitators who could help build partnership
relationships and local capacity. Partners viewed coaches as
especially vital to completion o their Local Partnership
Action Plans, which guided the work o each partnership
through the initiative.
3 Successful caches ere trusted by allmembers f the partership ad
uderstd the ctext ad histry f
the lcal cmmuity.
Tey also:
3 could navigate through challenging group dynamics
3 had strong strategic planning and group process skills
3 could be physically present at coalition meetings and
events.
Goals or local coaches included supporting the strategic
planning process and partnership development, as well as
transerring some o their skills to partnership leaders.
Coaches were highly successul in achieving the rst two
goals, which were critical to the uture success o the local
partnerships. In most cases, however, coaches did not
achieve the third goal o transerring their acilitation and
planning skills. o transer skills to coalition leaders,
coaches need additional, dedicated time to engage these
leaders in skill-building activities and could benet rom
having training and skill-building materials to help them.
3 Peer learig as a perful tl frpublic health departmets.
Peer learning, PPH ound, was the most powerul tool or
building the partnership capacity o public health
departments. PPH created several venues to bring together
health department leadership, managers and sta to identiy
barriers to and strategies or partnering eectively with
communities. Trough interviews and meetings, health
department personnel identied approaches or building
community partnerships, including:
3 elevating the value o engaging in CBPH
3 unding inrastructure development o local health
departments in ways that support CBPH
3 unding inrastructure development o community
groups so they can ully participate in partnerships
3 securing nancing that supports CBPH in the local
health department and community
3 developing evaluation methodology that highlights
the value o community-engaged approaches to
health improvement
3 acilitating policy changes that support CBPH
through nancing, reorganization or developing
community-based programs.
lESSonS
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Peer learning models were most eective when they:
3 brought people together rom dierent health
departments, including directors, managers and
ront-line sta
3 highlighted models that worked well
3 created opportunities or people in similar positions
to share their experiences, successes and challenges
3 created opportunities or sta and managers to talk
with directors within their own health departments.
Tis was limited to a ew places, and was not
acilitated or mediated by PPH. Had this been done
more actively, possibly with proessional and
academic support, there might have been greater
institutionalization and sustainability o PPH eorts
in more places.
3 Flexible fudig fr techical supprtas crucial t buildig capacity.
Providing local groups with unding that was earmarked or
training and capacity building allowed groups to identiy
local resources and develop relationships with individuals
and organizations within their communities or regions. It
also built the capacity o the group to identiy and address
their own training needs. It was important that these unds
were administered centrally, so that community groups did
not eel that money was being taken away rom their own
budgets to carry out these programs.
3 Partership develpmet beetedhe parterships ere respsible fr
idetifyig ad executig sme f their
techical supprt.
Incentives or community groups and public health
departments to collaborate in planning and carrying out
local training or their own sta were powerul tools or
supporting partnerships and building relationships.
PPH established a host model training und o up to$3,000 per partnership that could be used or training, i
partnerships provided matching resources. PPH also
provided technical support, as needed, on how to plan and
carry out a training program. Virtually all PPH grantees
took advantage o this resource, and many pooled their
unds to sponsor multi-day retreats and training programs
or their coalition members. Tese programs created early
successes or coalitions as well as opportunities to build
relationships and other skills at the same time.
3 Cllabrative self-assessmet tls cabe very effective i idetifyig ad
helpig calitis build their capacity t
fucti effectively as a cllabrative.
Most collaboratives, however, are not likely to take the time
to use these tools unless it is a requirement o unding or
tied to the incentive o some additional supportsuch as
consultant services, unding or a specic training.
Based on the experience o PPH, it would be most
benecial to communities to introduce this kind o tool at
the beginning o the initiative, so it becomes a standard
practice. Repeating the sel-assessment once a year, moreover,
is an eective way to tune-up coalition unctioning.
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In choosing to use a participatory approach to evaluation, the Partnership or the
Publics Health initiative made a noteworthy and difcult commitment to power-
sharing and openness.
Participatory evaluation means dierent things to dierent people. o some, it
means including participants in the learning and evidence-building process, but
not necessarily giving them control. o others, participatory evaluation requires
that the people and programs being evaluated have ull control and oversight o
all evaluation activities.
In most cases, participatory evaluation has been implemented in small
community projects with a limited number o stakeholders. In these situations,
control and oversight by all stakeholders over evaluation questions, methods and
reporting may be a reasonable expectation. However, when participatory
principles are applied to a large project like PPH, a great deal o adaptation and
innovation is needed to coordinate even limited stakeholder participation in the
evaluation process. Because evaluation o the PPH Initiative applied a participatory
evaluation approach on a larger scale and in a more complex setting than most
earlier projects, the experience provides important lessons about the difculties
and benets o this approach.
evaluationdesignandinfrastructure
Te size and complexity o the initiative called or a multilevel evaluation design
that acilitated communication and connection among all key stakeholders. Te
PPH Program Ofce, which was established to support and monitor the
initiative, contracted with the Center or Community Health and Evaluation
(CCHE) or evaluation design and management. CCHE brought to PPH
evaluators experienced in design and implementation o evaluations o
c
el cy
t PPh
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community health initiatives. Te team included local
evaluators who were chosen by the local collaborative
partners and then worked closely with the local partnerships
to monitor and document progress and support
development o local evaluation capacity. Te PPH Program
Ofce also hired an evaluation coordinator to work with
CCHE to ensure coordination o program and evaluation
activities. Finally, an Evaluation Advisory Sub-Committee
supported PPH by sharing insights rom the experiences o
other community-based health improvement initiatives and
oering their expert advice on every aspect o the PPH
evaluation process.
creatinganevaluationcommunity
Te participatory nature o an evaluation is commonly
envisioned as a relatively democratic relationship between
evaluators and grantees. Tis connection must also be built
into many other relationships. Te close working
relationship that developed between the sta o CCHE and
PPH was unusual or an external evaluator and program
ofce. CCHE and PPH shared inormation rom grantees
and coordinated program and evaluation activities throughregular meetings and communication. Monthly conerence
calls, moreover, acilitated the active participation o local
evaluators in the design o the evaluation process, methods
and instruments, helping to ensure that they were
appropriate to grantees needs. Te conerence calls also
provided opportunities or local evaluators to share ideas
and tools that they had developed with their partnerships.
In addition to these regular meetings, CCHE periodically
solicited eedback directly rom grantees regarding
evaluation methods and instruments. Te goal was to nd
as many avenues or stakeholder input as possible within
time and logistical constraints. Balancing the needs o all
stakeholders, especially those o the grantees versus the
under, involved a great deal o negotiation and
compromise. In the end, excellent tools and processes were
developed, including a participatory progress assessment
process and modied approach to the case study method
that combined qualitative description with quantitative
inormation and standardized reporting.
Participatory evaluation was new to most PPH partners. As
a result, they needed an orientation to the multiple
purposes o evaluation, the nature o and rationale or
participatory evaluation and a clear designation o the roles
and responsibilities o each stakeholder (i.e. the local
evaluator, community activists and health department sta).
It was particularly important to communicate the act that a
participatory evaluation coners upon grantees responsibility
along with authority.
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lESSonS
3 Addressig the iterests f multiplestakehlders thrugh a participatry
evaluati is likely t yield multiple
perspectives accmplishmets.
Grantees want to know how to improve their programs,
and grantmakers want to understand the outcomes o their
investment. Participatory evaluation argues or the
presentation o each perspective, particularly when
signicant dierences emerge.
3 Prgress i buildig lcal evaluaticapacity depeds the illigess f
gratees t assume a active rle i
evaluati.
Striking a balance between participation and the time
constraints o grantees presented an unresolved challenge
or participatory evaluation. Linking evaluation ndings to
sustainability eorts, particularly grantwriting, was the mosteective strategy or stimulating grantee interest in
evaluation. Adequate unds or evaluation training are
essential. Stipends or residents who organize and conduct
local evaluation activities should be seriously considered.
3 It is essetial t create pprtuities frlearig amg the members f the
evaluati team at all levels f the
iitiative.
Tis learning occurs through the exchange among local
evaluators, the community and initiative-level evaluation
sta. It also applies to creating a mechanism or ongoing
dialogue between the evaluation team and under. Periodic
discussion and reection helped ensure that the interests
and questions o the under were addressed in the evolving
evaluation design and that the rationale or key evaluation
decisions was ully understood. Te dialogue also created a
deeper understanding o the potential, limitations, and cost
o participatory design.
From Te Endowments perspective, however, there were
some downsides to participatory evaluation, especially or
such a large initiative. Te volume o data made it hard to
know which actors were important and which were not. In
addition, because the relationship between evaluator and
grantee is so interactive, objectivity is sometimes lost, and
evaluators come to see themselves as advocates or grantees
rather than more or less objective observers looking or
opportunities to strengthen the initiatives work. Tere were
also some challenges in having the Program Ofce manage
the evaluation. Finally, the scope and complexity o the
initiative made it difcult to distill ndings in a digestible
manner. Tat, in turn, made reporting to oundation
trustees difcult, overly complex and nuanced in all ways.
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At the core o the PPH initiative was the relationship between public health departments
and community residents. A key mission o PPH was to invest in building the partnerships
between health departments and local communitiesencouraging them to work together,
agree on community health priorities and jointly develop strategies to address them.
Forming these partnerships was difcult. In many cases, partners had to overcome legacies
o mistrust between communities and government agencies as well as power dierentials
that had characterized their interactions in the past. In addition, communities and public
health departments oten had little understanding and appreciation o their respective
resources, roles and responsibilities.
Public health department sta requently lacked mechanisms or eectively communicating
with and involving community members. Prior to PPH, some health department sta
undervalued residents ideas and approaches to health issues. Others ound it challenging to
work with volunteers, whose availability is oten limited by job and amily responsibilities.
At the same time, communities oten lacked an understanding o the local public health
departments responsibilities and operations. Some groups ound it challenging to work with
a government agency that seemed inexible and slow to act and whose public health
priorities seemed to ignore issues o local concern. In many cases, community members did
not know how to access the resources o their local health department, as they began
addressing the health issues they had identied.
Despite these hurdles, however, many strong partnerships did emerge during the course o
the PPH initiative. In the process, the initiative was able to identiy organizational models,success actors and strategies that enabled public health departments to work productively
with local communities. Based on lessons learned rom the initiative, Te Endowment
continues to push or strengthening capacity, standards and accountability or community-
based public health partnerships.
bl s
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CollaBoratIng to aCHIEvE long-tErm CHangE
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3 It as challegig fr sme public healthdepartmets t frm parterships ith
several cmmuity grups at ce, as
required by the iitiatives desig.
Tis was especially true in Los Angeles and all public health
jurisdictions that were responsible or an entire county and
lacked sufcient sta to work simultaneously with
numerous local community organizations.
3 Per sharig is at the ceter fpartership.
Learning to work together, share power and appreciate each
others assets was key to building a productive community
health partnership. More power traditionally resides with
local health departments, which have greater access to
government resources than community groups do.
Partnering or community health, however, oten required
shiting the power balance in the partnership. As one healthdepartment sta explained, public health departments have
resources, data, government connections and some clout.
Community partners, however, have more power when it
comes to working with residents on everyday issues such as
beat cops, speed bumps and grocery stores and other
neighborhood concerns.
3 Successful parterships created a sharedvisi.
Communities and health departments oten had dierent
priorities, goals, agendas, ways o working and timetables.
In many cases, the health department was more data-driven
while the community was motivated more by a passion or
residents well-being. Many PPH community grantees did not
have an existing working relationship with the local health
department. Some even had past experiences that had let
them wary about working with the public health agency.
Tose partnerships that were most successul paid attention
to developing a shared vision or their collaboration. Tis
process oten helped them recognize their commonalities,
understand each others assets, resources and limitations and
have realistic expectations o what each could contribute.
As one community group leader noted, We shared
responsibility to improve community health and brought
dierent resources to the task. Another explained: Ourwhole PPH partnership has been about learning where our
interests and assets intersect.
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3 Strg parterships bridged culturaldiffereces.
While working together, health departments, community
groups and residents oten discovered cultural dierences
based on values, historical experience, heritage, language,
socioeconomic background, world views or institutional
mission. Successul partnerships ormed their own culture
as they worked to bridge those dierences, solve major
problems and adapt to internal and external challenges.
Tey also created an environment o respect that
acknowledged the range and validity o diverse perspectives
and allowed or the meaningul participation o all
members. Strategies or eective partnering included:
3 touring the health department and the community
3 taking time at meetings to share the history and
structure o each organization and explain how tasks
are accomplished
3 becoming more or less ormal in work styles to bridge
organizational dierences
3 simpliying language and reducing the amount ojargon used in meetings
3 jointly hosting and participating in trainings,
community celebrations and educational orums
3 providing language interpretation to enable
meaningul participation by all community members,
not just English-speakers
3 creating an environment o open communication and
identiying mechanisms or sharing inormation
regularly
3 rotating leadership and sharing power
3 nding ways, through social and work-related
activities, to build relationships between health
department sta and community group members.
3 Partership frmati ad maiteaceis a cyclical, dyamic prcess.
Like many groups, CBPH partnerships go through the
our-stage process o orming, storming, norming and
perormingtesting boundaries, airing conicts, resolving
them and accomplishing tasks. Tis cycle repeats every time a
new partner comes into the group and changes the mix. As a
result, partnership building did not just occur in the beginning
months and years o the initiative. It was a continual,
dynamic, oten challenging process or even the most stable,
successul public health and community group partners.
Pp l w
l, y,
ll p
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lESSonS
3 Public health departmets that eremst successful i parterig ith
cmmuities had a brad base f
leadership.
Some public health directors were clearly committed to
community-based public health, but lacked an organizational
development strategy to make community work anything
more than a sideline activity or short-term grant program
that did not change the ocus o the organization or existing
categorical programs. Conversely, there were examples o
deeply committed sta and middle managers, who, without
the support o the public health director, could not move
the vision o community-based public health beyond the
program level to inuence the organization itsel.
When leadership was truly dispersed rom top to bottom,
however, the structure and culture o the organization
supported CBPH, especially in public health departments
with established organizational divisions committed to
working with communities. In these agencies, the
legitimacy o CBPH work was not only reinorced, but the
sta also became peer leaders in advancing the CBPH
ethos. Tese ormal organizational divisions nourished sta
leadership and would not have been possible without
support rom senior management.
3 Exteral surces f leadership ereimprtat i sme public health
departmets.
Community advocates, agency executives and elected
ofcials were variously useul sources o support or
community-based approaches to public health. In
Mendocino County, or example, the public health
department organized a Public Health Advisory Board that
included partnership members as well as physicians and
representatives rom county government. Incorporating
those external sources o support and leadership into public
health department program and advisory unctions helps
sustain their impact and contributions.
3 Sme lcal public health fcials frmedregial frums t pl leadership ad
lear frm e ather.
An eight-jurisdiction group in the San Francisco Bay Area,or example, came together with PPH support to develop
regional strategies to address health inequities. Tey also
ocused on internal capacity building and organizational
development processes, enabling sta and senior managers
rom the nine public health departments to consult with
and learn rom one another about how to engage
communities. A six-county collaboration in the Central
Valley is also in the early stages o sharing leadership skills
and knowledge to encourage CBPH practice and work
more eectively with communities.
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3 Cmmuity-based appraches t publichealth trasced specic public health
prfessis ad trade assciatis.
As a result, one difculty in gaining broader support or
CBPH is that existing public health organizations are built
around proessions. Tey typically represent their own
interests and do not commonly adopt approaches that cross
proessional boundaries.
communityleaders
Leadership development is also essential to the sustainability
and growth o community organizations. Sta turnover is a
act o lie in community groups, which work with very
limited, short-term budgets to address complex, long-term
projects. As a result, burn-out can occur among even the
most seasoned and committed leaders.
New leaders oten emerge naturally through participation in
working committees, volunteer boards, programs or projects.
In one Shasta County partnership, or example, PPH-unded
minigrants turned dozens o local residents into project
leaders. In addition, structured leadership training programs
can give residents the skills to step into leadership positions.
3 Cmmuity grups shuld makesuccessi plas.
Given the high turnover that many community organizationsexperience, it is important or them to ensure that they have
new leaders in the pipeline. o prepare them, groups should
also structure opportunities or them to take the reins and
gain experience in dierent kinds o leadership situations.
3 Leadership traiig prgrams casuccessfully develp ad idetify e
leaders.
At the outset, nearly all PPH community partners identied
leadership development as a priority or action. Tose that
incorporated a broad training program that taught residents
the basic components o community health improvement
rom assessing needs and mapping assets to developing
programs, changing policy and undraisingcreated a cadre
o program leaders who could participate eectively in a
variety o arenas. Partnerships provided leadership training
in a wide range o skills, using a variety o ormats and
approachesranging rom weekend workshops to year-long
training programsthat took into account participants
work and amily responsibilities.
Groups that wanted to expand their advocacy role provided
leadership training in public speaking, presentations,
decision-making processes and data collection and
interpretation. Other organizations ocused on improving
internal operations and provided training in nancial
management, board development, meeting organization
and acilitation.
Te trainings were most successul when they combined
skills needed in the organization with the interests o
participating residents. Without that mix, residents typically
gained skills but did not necessarily contribute to the
growth, development and leadership o the organization.
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lESSonS
3 Residet egagemet icreased hegrups ffered a rage f pprtuities
fr ivlvemet.
Residents get most enthusiastically involved in their
personal areas o interest. One resident, or example, might
be especially interested in unding issues and nancial
sustainability, while another might be interested in outreach
or youth activities. Only a small group o residents might
actively participate in planning, while a larger group might
be interested in more action-oriented implementation
projects. Oering several routes to involvement boosted the
rate o resident participation.
In San Diego, or example, residents had a choice o teams
and topics they could work with, rom community saety
and nutrition to parenting and substance abuse. Residents
oten started with one team, then moved into others as their
interests changed over time.
According to a partnership coordinator, residents are morewilling to get involved when there isnt a rigid agenda. Te
director o another San Diego partnership agreed: Its so
important to keep the issues moving. Dierent people step
up, depending on their interests, and thats what keeps this
partnership alive and energized.
3 Makig meetigs accessible fr residetsas critical fr their ivlvemet.
Tis oten meant scheduling meetings at nights and on
weekends, with plenty o advance notice, and holding them in
amiliar, accessible locations like churches, schools, parks
and peoples homes. Tey also encouraged participation by
creating a welcoming atmosphere with ood, childcare,
interpretation and translation, youth involvement options
and transportation or youth and seniors. Most partnerships
learned many o these crucial strategies through trial and error.
3 Cmmuity members ere mre likelyt egage i health imprvemet effrts
that prvided them ith pprtuities t
lear e skills.
Some residents, moreover, moved rom their own training
to greater involvement in eorts to improve their
communities. In Long Beach, or example, the PPHpartnership produced dozens o new community health
leaders who provide health education to amilies and other
community residents, organize health airs and cleanups
and teach classes on nutrition, health and physical activity.
Teyre the driving orce o a lot o community agencies in
the area, said a community partnership coordinator. Some
o them may not have more than an elementary-school
education, but theyre taking the lead on local issues and
being invited to give speeches at universities.
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3 Ivlvig residets frm differetcultures as a critical part f residet
egagemet.
It was especially important to identiy leadership in each
culture and bring them to the table. In San Joaquin County,
or example, the public health department collaborated
with diverse partners representing Stocktons distinctive
Southeast Asian, Latino and Arican-American
communities. Tese collaborations were intensive and took
up an enormous amount o time, noted the countys
director o public health, but they also transormed the way
the department worksincreasing awareness, or example,
o how cultural belies and attitudes can aect health. Te
partnerships diversity also proved to be a strength, especially
in mobilizing support or community health services.
When the county considered scrapping mobile health
programs that traveled to underserved areas o South
Stockton, or example, a diverse coalition o PPH partners
and other community-based organizations turned the tide.
Residents o local groups joined Hispanic, Hmong, Lao and
Arican-American residents o South Stockton at a county
Board o Supervisors meeting to show their support or the
jeopardized health programs. As a result, the supervisors
voted to continue most o the services and pay or them out
o scarce county unds.
Te diversity o our coalition was part o the leverage that
saved these programs, explained a community partner.
Decision makers see that we represent multiple groups, not
just one narrow interest. When all the communitys
dierent residents work together, things happen.
3 Several factrs ere istrumetal ieablig health departmets t make
chages that supprted a sustaied
cmmuity-based fcus:
3 Leadership that uderstd ad clearly ad
csistetly cmmuicated the value f
rkig ith cmmuities. It was critical that
health department leadership was able to persuasively
articulate the benets o working with the
community and actively look or opportunities toapply a community-based approach in existing
programs as well as in planning new programs.
3 Creative acig that priritized rk ith
cmmuities. PPH health departments adopted a
number o dierent strategies to identiy unding tha
was exible enough to support community-based
public health, including local general und or state
realignment monies, exible use o categorical unding
and creative use o bioterrorism preparedness unding
3 Istitutialized mechaisms fr icludigcmmuity iput i health departmet
prgram plaig ad implemetati.
Examples o input mechanisms included community
advisory boards, direct involvement o community
members in assessment and planning processes,
hiring o community residents as sta and regular
public orums.
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Community health improvement is sustained through policy and systems changes.
Tese eorts, during the PPH initiative, were most successul at the local level. PPH
partnerships were able to identiy community health issues including broad determi-
nants o health, ranging rom access to care, youth development, nutrition and physicaactivity to environment, violence, sanitation, trafc saety, housing and transportation.
Examples o policy and systems changes ranged rom increasing ambulatory care
and transportation services, limiting alcohol distribution, establishing a dioxin
monitoring station and creating a local park. In Shasta county a partnership helped
persuade the school board to adopt a healthy-oods policy or the district and in an
unincorporated area o Los Angeles, another partnership helped build support or a
new garbage disposal district.
Sustaining community partnership eorts requires broad changes at both local and
state levels. Te ollowing three policy and systems changes would bolster
partnership eorts and improve community health in Caliornia:
3 Local public health systems should support broad prevention strategies or
improving the health o communities. o achieve signicant community
health improvements, public health departments need organizational
structures, nancing, stafng, data capabilities and leadership that support
collaborative work with communities and public and private organizations.
3 Perormance Standards should be established to support community health
improvement. Perormance standards should be tied to broad goals or
community health improvement. Models o accountability should alsoextend beyond ormal public health governance to include community and
other agency partners.
3 State-level public health ofcials should provide strong leadership to achieve
major community health improvement goals. o signicantly improve
community health, state health departments and organizations must support
broad public health improvement strategies as well as collaborative partnership
that extend beyond the ormal boundaries o public health agencies.
Ll Ply
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Ply y
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CommunIty partnErS takE tHE lEad
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lESSonS
3 Lcal health departmets, as publicistitutis, are smehat cstraied i
their ability r illigess t take a lead
rle i advcacy effrts.
As a result, community groups oten take the lead when
solutions to their health concerns require advocacy or local
policy or systems changes. Te communitys ability to
articulate local perspectives, personalize the issues and
mobilize large groups o residents to attend public orums
and hearings can eectively capture the attention o local
policymakers.
3 Public health departmets ca help buildthe capacity f cmmuities t egage
i the public plicy prcess.
Tese eorts can include helping community members
develop advocacy skills and demystiying the policy process
through leadership training programs.
3 Lcal health departmets ca assist adsupprt cmmuity advcacy effrts.
Many o the 14 health departments that participated in the
PPH initiative provided training, data and other documents
to support the communitys policy positions and
presentations. Health department directors were also able to
open doors or community leaders to meet with key local
decision makers. Open avenues o approach between local
politicians and health directors were essential in order to
keep politicians aware o important local health issues. Te
mere presence o health department leaders at publicorums also helped to support and add legitimacy to
community eorts.
t y ly
l ll pp,
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ll ply
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Federal, state and local public health is still largely ocused on traditional
unctions, primarily inectious disease control, maternal and child health and
health education. As a result, there are major barriers to making policy changes to
support community-based approaches to chronic disease prevention and
addressing the social determinants o health and health disparities. Withoutunded systemic and institutional change, CBPH approaches and programs
while innovative and led by dedicated public health and community workers
will likely remain marginalized.
In order or internal public health inrastructure changes to take place, policy changes
must include specic unding to support community-based work, reorganization
o public health systems to support CBPH and incorporation o CBPH
principles into academic programs to prepare the uture public health workorce.
PPH advocated extensively or these changes on a statewide level. However, those
eorts collided with two major orces in Caliornia public health and revealed the
magnitude o the task. First, prior advocacy or local public health departments
in Caliornia has concentrated almost exclusively on strengthening capacity or
inectious disease control, which has eroded dangerously over the past ew
decades. As a result, some viewed as an unaordable add-on the suggestion that
public health ought to have a broader vision, involving partnerships with
communities and other public and private agencies. Some also eared it
represented a privatization o public health and would divert scarce resources
rom local public health departments to other entities. In addition, some
questioned whether there was scientic evidence to support CBPH or a workorce capable o carrying it out.
Secondly, the inusion o ederal unds and short planning timelines or
bioterrorism and emergency preparedness monopolized the intellectual resources
o public health leadership throughout the state, crowding nearly everything else
a cll m
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cbPh pp
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CHangIng StatEwIdE puBlIC HEaltH polICy
achallengingmission39
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o the agenda o statewide public health planning. Local
health departments, acing substantial budget cuts, also
shited sta rom threatened programs to bioterrorism
unding, urther undermining the base o support or
community-based public health. Moreover, these
circumstances reafrmed the centralized command-and-
control culture associated with emergency responseat the
very time that PPH was calling or power sharing,
institutional humility and community partnerships.
An additional actor may have been the absence o strong
leadership at the state level. While Caliornia has some areas
o strength in its public health inrastructureits tobacco
control program, or example, is a model or the nation, i
not the worldthere is little evidence o creative vision
overall. Public health was a low priority in a combined
health and human services agency that was subject to tight
political oversight. As a result, PPH was unable to benet
rom a statewide public health planning process or create
momentum in the proession.
Consequently, by the end o the initiative in 2004, PPH
had not achieved as much as hoped in its eorts to promote
changes in statewide public health policy. Nevertheless,
PPH did help lay important groundwork or community-
based public health in Caliornia and learned important
lessons and strategies or promoting statewide policy
changes. Te initiative helped create a common ramework
and language. It gave rise to a cadre o public health
proessionals who think dierently about their mission and
scope and the broad actors that determine the health o
their communities. It also helped raise the visibility o
chronic disease prevention as a public health mission. Tis
has been incorporated into the work o a new statewide
Department o Public Health, approved by the legislature in
September 2006, even though it was not part o theoriginal, legislated vision or the department.
PPh p p
w pl l ply, lp ly
p w cbPh cl
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lESSonS
3 T persuade a public health audiece,argumets must be based evidece
abut the health f ppulatis ad
efcacy f preveti strategies.
It is not enough to assert the inherent value o working with
communities, even though that philosophical principle
might appeal to some. Te public health case or working
with communities must be based, instead, on evidence that
it is necessary in order to change the conditions that aect
community health. CBPH, like other developing currents
in the history o public health, must create the evidence
base to justiy itsel. Although that evidence is growingas
indicated by the Community Guide to Preventive Services
(www.thecommunityguide.org) or the developing interest
in Health Impact Assessmentsit has not yet achieved the
status o accepted practice.
3The PPH ccept as t diffuse ad
abstract t iuece the public health
rld.
Te end goal o PPH was improved community health, but
the vision o CBPH was oten vague and difcult to
communicate eectively. PPH involved 39 dierent
partnerships between public health departments and
communities, each looking at evidence and sorting out
relationships in order to decide their own priorities. As a
result, there was little common ocus among the
partnerships and little basis or a dening innovation in
practice. Te only common element was PPH itsel, and
that was not enough to convince the skeptical or the harried
that CBPH strategies and principles were sound.
3 Stateide public health plicy rk musbe de strategically, ad it must iclude
a uderstadig f public health
prfessials ad the ctexts i hich
they d their jbs.
PPH underestimated the depth o tensions over priorities o
public health throughout the state and how beleaguered ma
dedicated public health proessionals are as they attempt to
their best within a deteriorating public health inrastructure
Although PPH hosted a series o conversations among the
various statewide public health organizations, those outreac
eorts ailed to reassure their leaders that we were not askin
them to build a new edice on a crumbling oundation or
disperse the responsibilities and resources o local public hea
departments to others. All in all, PPH was not perceived as
ally engaged in complementary work, but as an adversary
making impossible demands. Although PPH built a strong b
o support among like-minded colleagues, its agenda did no
cross the threshold into broad acceptance.
3 PPH veremphasized the tp-dapprach i advcacy.
Although the vision o PPH was to build strong partnership
between local public health departments and communities,
with shared responsibility and accountability, its statewide
policy advocacy eorts were not generated by that grassroot
base. Faced with the short timerame o a oundation initiat
and the need to act quickly on simultaneous ronts, the
initiative could not develop that base quickly enough to cra
and carry a policy message. Because a broad base is a much
more persuasive orce than a small band o advocates, PPH
ultimately see more long-term success when its grassroots ba
is strong enough to promote its policy agenda.
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3 Persistece ly pays ff ver time.
In statewide policy advocacy, PPH took uncharted paths.Te value in that process is learning rom mistakes and
correcting them. In retrospect, persistence was perhaps the
most important element o the initiatives policy eorts. By
ocusing consistently on community-based public health
and supporting local eorts to pursue it, PPH helped set
CBPH roots around the state that will yield policy and
system changes in the uture.
Looking orward, the ollowing steps will help create urther
policy and systems changes in support o CBPH:
1. Develop capacity in the new Caliornia Department o
Public Health to support and guide local CBPH eorts.
2. Use the obesity prevention platorm to build a critical
mass o CBPH-engaged local public health departments
and communities.
3. Integrate CBPH into ederal (e.g., USDA and CDC)and state agreements with local public health departments.
4. Foster the expansion o local public health departments
and their involvement in civic planning and decision
making to benet a health-supportive built environment.
5. Seek avenues to support policy that will provide a
permanent unding stream or chronic disease
prevention through CBPH approaches, beginning with
obesity prevention ocusing on environmental change.
6. Support day-to-day preparedness or the greater burdeno disease as well as other orms o preparedness.
7. Develop cross-sector leaders in CBPH, including PPH
alumni and others rom the Healthy Eating, Active
Communities (HEAC) program and aligned CBPH work.
8. Continue to strengthen community capacity to partner
eectively in CBPH.
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While nancial resources are key actors in sustainability, it takes more than
money to sustain community health improvement eorts. It also takes a
substantial investment o timeperhaps ten yearsto build capacity and
inrastructure in community and public and private agencies to see community
health improvement eorts take root and ourish.
Nevertheless, PPH built an important oundation or community-based public
health in Caliornia. Te initiatives ocus on capacity building and partnership
development also helped create a deeper understanding o what is needed to
sustain this work beyond an intitiatives unding period.
Communities also need the social capital, organizational networks (within and
outside the community) and nancing, sta and leadership to address a wide
range o community health issues. Public and private agencies need to understand
how their missions overlap with the goals o community health improvement.
i n J my
i l pp 8 10 y
l pl cbPh w
SuStaInIng CommunIty-BaSEd puBlIC HEaltH partnErSHIpS
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3 Sustaiability icludes the capacity ttake additial issues as they emerge.
Partnerships that ocused on more than one issue were able
to enlist the support o broader constituencies. Tey were
also likely to generate new support both within and outside
o the community as their agenda expanded.
3 Fudig issues, f curse, are critical tsustaiability.
Te challenge or both health departments and community
partners, especially in times o limited resources, is to seek
unding that addresses recognized needs o the community.
Grantmakers can help grantees in their sustainability eorts
by discussing, providing training and oering resources or
sustainability planning early in the unding cycle.
Grantmakers should also be willing to invest in grantees or
a new phase o development. Moving on to a newcommunity may be attractive or a variety o reasons, but it
may also mean missing important opportunities to build on
past achievements.
g lp y , p
ly pl ly
yl
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In the period between the end o the PPH initiative and the publication o this
lessons learned document, there were many important developments that alter
some o this reports conclusions about policy change. Still, the premise o
persistence paying o over time must be underscored as one o the overriding
lessons o this initiative.
newfocusoncollaboration
Te public health policy environment in Caliornia has changed signicantly overthe past three years, gaining a new ocus on collaborative approaches or
addressing the social and environmental determinants o chronic disease.
Although bioterrorism-preparedness eorts drove legislation creating a new
Department o Public Health, the department, once created, along with the
organizations that promoted it, embraced a larger vision or its mandate, given
the growing acknowledgment o obesity as an actual (as opposed to potential)
risk. Foundation initiatives were already demonstrating the contributions o state
and local health departments, community partners, public and private agencies
and policy advocacy as important means to achieve environmental changes to
improve health.
A governors summit on obesity and comprehensive state obesity prevention plan
provided new openings or state leadership and ostered a greater convergence
between state health department work and oundation initiatives. A Caliornia
Health Strategy Summit also highlighted the importance o both communicable
and chronic disease as threats to the health o the population, urther legitimizing
the expanded vision or public health.
Eie
a y l
p py
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Finally, and not least importantly, many local health departments, in spite o the
unding and organizational challenges, were developing strategies to conront the
challenges o chronic disease.4 As a result o these combined orces, there is
considerably less riction today over the priorities or public health in Caliornia, and
there are many promising examples o agencies and organizations working together.
While it is unreasonable to ascribe these changes to PPH, it is air to say that the
initiative served as an important catalyst, ostering capacity in local health
departments and building a statewide momentum or community-basedapproaches to public health. A new vision, buoyed by evolving models, can be
important even when it is initially marginalized; and it can pay o immensely
once it has had time to ourish. Many promising practices o local health
departments that are working with communities on broad determinants o health
were inuenced by the Partnership or the Publics Health, and to the extent there
is a constituency or this work, it reects the legacy o PPH.
oday, there is growing acknowledgement o the initiatives role. Te strongest
indicator o its inuence, however, is the transition o its vision rom controversial
to commonplace.
4 See, or example, Prentice B, Flores G, Local health departments and the challenge o chronic disease: lessons rom Caliornia, Prev Chronic Dis[serial online], Jan.,2007 (http://www.cdc.gov/pcd/issues/2007/jan/07_0081)
PPhs w p ly, l py ll l
p w cbPh
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