Health Equity Tools Are Key to Improved Policies and Outcomes
Experts reflect on the role of health-centered assessments and approaches in decision-making
Editor’s note: This text was updated on March 24, 2023, to correctly reflect Keshia Pollack Porter’s full name.
As U.S. communities continue to face troubling inequities in health outcomes—problems made more pronounced by crises such as the COVID-19 pandemic—policymakers have demonstrated a growing interest in improving health equity: the principle that factors such as race, income, or geography can negatively affect health and should be addressed, so that all people have opportunities to be as healthy as possible.
Health in All Policies (HiAP) is a collaborative framework for helping policymakers, industry, and community leaders understand the potential health effects of decisions they make. One such approach is a health impact assessment (HIA), which helps policymakers and researchers evaluate the potential health effects of a plan, project, or policy before it’s built or implemented, providing practical recommendations that may increase positive health effects and minimize negative ones.
The concept of health equity has become more important in recent years as policymakers grapple with complicated public health challenges. For perspective on how far the health equity field has come and where it needs to go next, we consulted with four experts: Tomás Rivera, executive director of Chainbreaker Collective, an economic and environmental justice organization; Keshia Pollack Porter, chair of the Department of Health Policy and Management and professor at the Johns Hopkins Bloomberg School of Public Health; Sandra Whitehead, president of the Society of Practitioners of Health Impact Assessment; and Pamela Russo, senior program officer with the Robert Wood Johnson Foundation.
These responses have been edited for length and clarity.
Q: How have you seen HiAP and HIA affect policy change, community engagement, or other outcomes your organization strives for?
Rivera: HiAP has helped us build power and be heard as we organize for economic and environmental justice. When our first HIA report indicated that our city—Santa Fe, New Mexico—was segregated, nobody was shocked. But the finding reopened the conversation about housing affordability and instability.
Pollack Porter: I’ve seen these tools change the way policymakers think about how policies in education, housing, and planning can impact health. I remember when state legislators mainly thought about Medicaid and access to hospitals when we approached them about health impacts. Now a growing number see that policies related to other sectors can influence health, and that social determinants of health also play an important role.
Whitehead: In particular, an HIA identifies trade-offs and helps engage a local community in an effort to lessen negative impacts before a decision is made. The affected community can bring to light concerns, opportunities, and knowledge that people planning a project wouldn’t have known otherwise.
Russo: First, HIAs can bring together community members’ priorities and evidence to influence decisions across many sectors, from transportation to land use to access to clean water—helping to shift the power balance. And to me, HiAP means that a community or local government has embraced the belief that there are health and equity implications to most decisions, and that these implications should be considered across all departments as part of standard operating procedure.
Q: What challenges have you faced in your health equity work?
Rivera: Building trust. Many community organizing groups do a lot for a little, but their work needs to be funded from both the private and public sectors, and those financial commitments are part of trust building. Often just the gesture of committing means more than the money itself. When we get a city council to approve funding for our work, it’s a statement in and of itself.
Pollack Porter: People who have power are afraid to lose it and are complicit in maintaining the status quo. So I often face resistance to making the structural changes related to power and dismantling structural racism, which are necessary steps to advancing and ultimately achieving health equity.
Whitehead: HiAP practice has become more defined as more organizations adopt it as a framework, but it’s not mature enough for a comprehensive evaluation on whether it’s effective. A few organizations have tried to evaluate their HiAP work, but examples of how to do those evaluations are limited. Then, because HiAP practice hasn't been systematically evaluated, it is hard for us to build a case for expanding it.
Russo: It’s still difficult to change mindsets and narratives—for example, a viewpoint that blames an individual for their poor health outcome or a value that not all people are deserving of that better outcome. Or, sometimes, community members bring their priorities to decision-making bodies, and their knowledge is gaslighted and their points dismissed.
Q: What are your hopes for the field in the next five years? Or even the next 10 to 20?
Rivera: That we continue to do the work, organize, and trust people. We need to recognize that community members are the experts. And we need to make sure that the people impacted by a decision have a voice and are leading the process.
Pollack Porter: I hope that growth in HiAP continues. I’ve been teaching HIA for 13 years, and the course that I teach today is more about HiAP than when I started. I often tell my students that there’s no one way to “do” HiAP, so I hope to see new tools developed that make it easy for communities, policymakers, and decision-makers to routinely consider the health and equity implications of their proposed actions.
Whitehead: I would love to see HiAP training become standard for public health professionals and their partners in the field. This would include professional skill-building and certification in the first five years; getting HiAP tools into public health college curricula while expanding professional education in 10 years; and creating a new way of doing business, with HiAP activities and tools embedded into our normal ways of doing business, in the next 20 years.
Russo: I’d like the implications for health and equity to become operationalized in processes and decisions as a norm. And I’d like to see a community group that has had success bringing a health and equity lens to a decision continue to apply this approach to other decisions.