NACCHO is pleased to recognize Harris County Public Health (HCPH) as a recipient of the 2016 Local Health Department of the Year Award. This award recognizes and honors outstanding accomplishments of local health departments (LHDs) across the country for their innovation, creativity, and impact on communities.
HCPH provides comprehensive public health services to Harris County, Texas—the third most populous county in the United States. It has an annual budget of over $80 million and a workforce of more than 700 employees.
HCPH’s serves approximately 2.2 million people within the county’s unincorporated areas and 33 independent municipalities (excluding the city of Houston). For certain public health services such as mosquito control, Ryan White HIV/AIDS Program Part A, and refugee health, HCPH’s jurisdiction encompasses the entirety of the county, including the city of Houston, for a total population of more than 4 million.
Harris County is also one of the fastest growing and most diverse areas and faces a multitude of upstream challenges. It has a 19% poverty rate, 78% high school graduation rate, and 11 zip codes on a pollution watch list, all factors that are correlated with poor health.
Dr. Umair Shah, Executive Director of HCPH and NACCHO President-Elect, recently shared his health department’s experiences in working towards health equity in an interview with NACCHO Voice.
NACCHO: Please briefly describe your local health department and the population it serves.
Dr. Umair Shah: We are a comprehensive public health agency in the Harris County, TX, jurisdiction, which is the third most populous county in the United States, with 4.34 million people spread over 1,778 square miles. That makes our county larger than the size of Rhode Island with four times the population. In fact, if Harris County were a state, it would rank between Kentucky and Oregon as number 27 in population size. Our community is diverse in every sense of the word and is growing tremendously. We are also home to the fourth largest U.S. city, the city of Houston. Our public health agency has been around since 1942 and it does what you would expect of public health agencies across the system. We have been known in the past for our strength in emergency response and infectious disease activities. More recently, we have moved into areas around chronic disease prevention, built environment, health innovation, technology, engagement, and, obviously, health equity. And those latter three—innovation, engagement, health equity—are the basis for this Local Health Department of the Year recognition.
NACCHO: Please describe the challenge or issue that led your LHD to embark on a journey of health equity.
Dr. Shah: I have been at this department for several years, starting in 2004 as the deputy director; in May of 2013, I was appointed the executive director. When I took over the agency, our budget was about $62 million with 500 people, and we had just undergone budget cuts and loss of staff in 2009–2010. This forced us to the think “out of the box” and make changes in how we do things, looking at innovative approaches where an LHD would have more impact—like upstream thinking. We are now well over $90 million and currently have over 700 people. So we have gone through an incredible amount of growth and transformation, while at the same time really looking at how we can improve the health of our community as it grows.
What we have learned over the years is that we had previously been mired in health disparities language. We then moved to health inequity language and now we have moved towards [applying a] health equity lens in all areas and aspects of our department. So that’s really been our journey and it has been about a decade-long journey. I was a part of NACCHO’s health equity and social justice committee under long-time NACCHO staffer Richard Hofrichter [NACCHO’s Senior Director of Health Equity and Social Justice] for several years. I worked with Drs. Adawale Troutman, Tony Iton, Linda Rae Murray, and others whom I would describe in my mind as incredibly fantastic leaders in health equity work. Our previous departmental director, Dr. Herminia Palacio, also strongly supported this work.
We are obviously working towards that path, that journey, and, in time, we realized that we couldn’t follow anybody’s journey. We had to create our own and that’s what we wound up doing. In 2013, we created an Innovation and Engagement (I&E) unit, along with creation of a health equity coordinator position. It took a lot of work, effort, and time. But the health equity coordinator position in combination with our I&E team and other departmental changes really brought innovation and engagement into our department and the addition of the health equity focus were the three lenses that really led to the recognition by NACCHO. These two areas, along with our newly redesigned Office of Communications, Education, and Engagement, have allowed us to keep our focus on the community— our community.
NACCHO: What was your plan to address health equity? What were your initial goals? How did you plan on measuring success?
Dr. Shah: Our previous strategic plan in 2005 was very much about health disparities and the language around it. With our work with NACCHO, other partners, and a better understanding of the social determinants of health and how they impact health in general, our updated 2013–2018 Strategic Plan was created with health equity front and center. We had all the traditional values of excellence, compassion, flexibility, etc., but we also added that additional value of “equity.” As a department, we theoretically understood the importance of health equity and the importance of equity in general but I think the challenge for our department was [figuring out] how do you operationalize that? This health equity focus in our area of policy and planning really helped take it from theory to practice. We came up with numerous theoretical models of what health equity looks like in our department, our community, and how we could approach it. We also came up with some strategies and initiated a staff capacity-building learning collaborative using [NACCHO’s] Roots of Health Inequity course. We also developed our own Health Equity 101 course for all staff. We created a pathway that took us from theory to strategy. I think that has been the biggest step forward for us: moving from theory to strategy and, ultimately, [from] strategy to practice. How do we actually view health equity front and center and [ensure we] are not just talking about it but actually “walking the walk”?
To measure [the] success of operationalizing health equity practice, one needs a strategic planning process. You create an overall plan, plan how you are going to meet the objectives, and then utilize an evaluation framework that really allows you to go back to see how well you achieved those metrics. We have come up with an entire system in our department that has even been incorporated into [our] application for accreditation that is very much about how we move from this real theoretical health equity framework that we believe really works for our department to tangible goals that we can measure and quantify to our end goal. Our end goal is to [apply] the health equity lens throughout the department in every activity, all the time, and every day in whatever any staff member is doing in the community or in our clinics or in functional areas of the department (e.g., human resources). I believe the evaluation framework is where the rubber meets the road of taking theory to practice but also [helps hold] ourselves accountable to what we have said we are going to do. And all this is driven and supported by data and data systems, which we too must invest in to sustain our work.
NACCHO: How did your LHD implement this plan? What resources and activities were involved?
Dr. Shah: Specifically, I think it really speaks to the methodical process of laying out a vision, having a commitment to the vision, and putting resources to [achieve] it. The health equity coordinator position is a perfect example. We actually have created a health equity work group and learning collaborative. We have been thinking of new ways and platforms to engage our staff. The department has created a new TED-style communication platform called PH-Talks. One of those talks was about health equity, in which our coordinator talked about her own life journey. She spoke on how to explain health equity to one of her family members and why what she was doing now in her health equity work was very personal to her experience growing up. Connecting a face to the actual issue can take something very theoretical around health equity and personalize it.
We believe that equity goes hand-in-hand with the strategy of using innovation, technology, and engagement tools that allow us to push our work forward. This has included investments in communications tools, like revamping our website to be more engaging or making YouTube videos and utilizing social media to connect with our community—heck, even I am tweeting now (handles @ushahmd and departmental @hcphtx)! It is a culture of innovation and engagement that is being accomplished by our equity principle.
NACCHO: What challenges or barriers did you encounter during implementation and how did you overcome them?
Dr. Shah: The foremost challenge is that you have to have a vision for it and you have to have leadership buy-in. I think commitment is the number one thing. When you have commitment, vision, and buy-in, you really start to move pieces of the puzzle and start to push resources into a certain area. Understanding what health equity is and how it impacts all of us as a community makes us remember that we all have a role. It’s not as easy as just moving on to the next patient; [it requires] meeting the community where they are.
We have done that with enhanced community outreach such as organizing a community health soccer cup, a health village at a music festival, and even outreach at Wal-Mart.
Health equity should not be a “siloed” activity. Health equity and social determinants of health need to be the lens and the process by which you do any activity that you are engaged in. For example, if someone misses an immunization appointment for their child, and you simply chalk it off to non-adherence or the parent not caring but do not look to see the reason the person missed the appointment, you’ve missed the boat on [understanding] why that person has missed the appointment. So the lens actually has a whole ripple effect on [improving] your ability to serve that community member. So it’s not always more money or dollars—sometimes it’s just reframing the way you think about the problem, so you ultimately identify new, creative approaches for tackling the problem. That is really the key to our work.
NACCHO: What advice would you give to other LHDs seeking to embark on a similar journey?
Dr. Shah: First, we really appreciate NACCHO’s recognition for our work and our journey. The advice I’d give others is two-fold. One is you have to have leadership commitment, but you also have to take the first step of your own journey. This is our Harris County Public Health journey and it’s not going to be the same for every public health department out there. You have to take the journey based on what your local context is, what your resources are, and what you need in order to move forward. That frankly means you have to create your own story and your own narrative. You have to shine light on the importance of the work and talk about it at every opportunity. I think the challenge we find is that we oftentimes are looking for models of practice that others are doing, which is also important. But I think equally important is creating our own path. I would say let’s not get stuck by not knowing where to begin. Just begin wherever you can. Don’t just say, I don’t know how to swim so I’m not going to put my foot in the pool. Put your foot in the pool, feel the water. Let it carry you to a different place. Eventually you’ll start to learn how to take the steps towards health equity. This recognition wasn’t just about our work with health equity, which now drives everything we do; it also [reflects] the way we do things from innovation, our approach to engagement, our new website, using social media, figuring out ways to engage our staff, our partners, our community, and really doing everything that we can, even in practical response to issues such as Zika.
While we were thinking about our health department and the increase in capacity, we realized we had to be very strategic in how we build that health department. We didn’t want to build it just as we had it before. We really felt that it was important to build our health department not as the health department of yesterday or today, but “the health department of tomorrow.” And that means you need a number of things including use of innovation and technology, multidisciplinary teams, leadership and staff development, use of public-private partnerships, and engagement. You have to be willing to take risks because that is ultimately what will move you from where you are to where you can imagine you want your agency to be. You have to think about a profession that needs to be, oftentimes, very nimble and acting for the interest of the community while at the same time doing it in a way that people trust you and understand what you are trying to achieve. Shining light on the value proposition of why public health is important is the key to our work. Often, our work is invisible and we have to bring attention to why our work is important. When you do that, people value it, and when they value it, people are willing to invest in it. Ultimately, public health is an investment in a community’s health and well-being.