Advancing Health Equity: Facilitating Action on the Social Determinants of Health Among Public Health Departments

Achieving health equity, attainment of the highest level of health possible for all people, continues to be a challenge in the United States. Strong evidence indicates that the most promising strategies for advancing health equity are those that target the social determinants of health,¹ a reality of which many in the field of public health are aware, even as substantial barriers both prevent initiation of this work and make sustaining it difficult.² Action on the social determinants of health among public health departments can be bolstered by providing flexible and sustained funding for this work, by better meeting the research needs of public health departments, and by presenting research in a way that promotes cross-sector collaboration.

BARRIERS TO ENGAGEMENT IN PUBLIC HEALTH WORK

Flexible and sustained funding is extremely important for facilitating work on the social determinants of health among public health departments. Many public health departments face sporadic funding, one-off budget allocations for specific initiatives, disease-specific funding sources, and requirements to shift funding from one project to another as political priorities of policymakers shift. Yet, stable and adequate funding—flexible enough to respond to community priorities—is required to facilitate relationship building and knowledge transfer between public health departments and their collaborators. Efforts that are here today and gone tomorrow reduce not only the momentum and the effect of interventions but also the trust between public health practitioners and community partners.³

Another barrier to engagement in work on the social determinants of health among public health departments is limited availability of research to support these efforts. There is a dearth of available research on the cost, cost-effectiveness, and return on investment associated with interventions targeting the social determinants of health.^4,5 When this information is available, it is often at the national level, which may not provide adequate resolution to determine whether the intervention is effective in a local context.⁵ Few local and state public health departments have the capacity to conduct literature reviews or effect modeling in-house; many more would use this kind of research if it were made readily available in forms that public health departments could immediately use.

Academic research has produced an enormous wealth of knowledge about what works in public health and about how well various interventions work compared with others. But this wealth of knowledge is often buried underground. Public health departments report being put off by an overemphasis on methodological complexity, use of research jargon, inclusion of voluminous information, failure to draw specific conclusions from research findings, and failure to frame findings in a way that resonates with a broad range of stakeholders.^4,6 Unearthing the gems of insight from beneath the layers of academic terminology is beyond the capacity of most public health departments. Consequently, a barrier separates the wealth of knowledge from those who could put it to best use.

Although the value of much academic research is immense, if hidden, there are specific blind spots in academic research. For example, researchers have seldom compared interventions targeting the social determinants of health for their potential to improve health equity.⁵

IMPROVING THE EQUITY OF HEALTH OUTCOMES

The way to achieve greater action on health equity for public health departments is to reduce and overcome the barriers to working upstream.

Providing more flexible and sustained funding sources for public health departments to address the social determinants of health is key. This will necessarily involve shifting the balance of funding for these efforts away from time-limited sources such as project-specific grants and more toward sustained budgetary expenditures.³ Although much of the onus of this shift must fall on the policymakers who determine public budgets, public health agencies can become more effective advocates for health equity by exchanging strategies for success with one another. Innovative strategies include social impact bonds and public health levies to garner or maintain funding to address the social determinants of health. Platforms such as the Building Sustainable Financing Structures for Population Health: Insights From Non-Health Sectors workshop should be made available for public health departments that have successfully navigated these funding issues to share their insights with others.⁷

Additionally, more funding should be targeted to research the cost-effectiveness of interventions that address the social determinants of health. The demand for research on the cost, cost-effectiveness, and return on investment of interventions targeting the social determinants of health among public health departments is high, and increasing the availability of this type of information would better equip public health departments to make the case to stakeholders for adoption of these interventions.^4,5 The utility of this research could be further increased by tailoring the findings to local jurisdictions, by showing outcomes by sector, by showing effects on nonhealth as well as health outcomes, by evaluating the equity effects of interventions, and by showing these outcomes over both short- and long-term time horizons.³

Making research on the cost-effectiveness of interventions targeting the social determinants of health more plentiful and usable would support public health departments’ own decision-making and also would help them more effectively advocate for resources for public health efforts that cut across sectors, that have a strong return on investment, and that foster success in areas such as education, crime, and economic development, perennial concerns of elected officials. One approach to achieving these aims would be to have a funding mechanism that includes funding for both implementation of interventions directed at the social determinants of health and performance of a cost-effectiveness analysis. Such a strategy would begin to generate the stronger translational research base needed to further stimulate action in the field. Capacity to conduct cost-effectiveness analyses of interventions targeting the social determinants of health can be increased either through the collaboration of public health departments with academic institutions or through the use of user-friendly, Web-based modeling tools that would allow departments to compute these outcomes for themselves.⁴

There is a strong desire to engage health equity work among public health departments. Leveraging this desire to create meaningful change on the ground will require some modest, but essential, modifications to how philanthropic work and academic research are currently conducted. But with these changes, the potential to substantially improve the equity of health outcomes is clearly attainable.