strategies for building community-public health partnerships

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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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2PartnershiPforthePublicshealth



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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.

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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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for BuIldIng CommunIty and HEaltH dEpartmEnt CapaCIty

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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

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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.

creatinganevaluationcommunity23


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27/52

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.

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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.

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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.

leadingchange3


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36/52

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.

engagingresidents35


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39/52

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.

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CommunIty partnErS takE tHE lEad

localPolicyandsystemschange37


40/52

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.

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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

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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.

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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.

achallengingmission4


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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.

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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.

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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.

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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)

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strategies for building community-public health partnerships

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