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- Background Paper 13 -
A national partnership for acA national partnership for acA
national partnership for acA national partnership for action to
tion to tion to tion to
end health dend health dend health dend health disparities in the
United Statesisparities in the United Statesisparities in the
United Statesisparities in the United States
Mirtha R. Beadle 1
Garth N. Graham 1
Paul E. Jarris 2
Carlessia A. Hussein 3
Alan Morgan 4
Ron Finch 5
1 Office of Minority Health, U.S. Department of Health and
Human Services
2 Association of State and Territorial Health Officials; USA
3 National Association of State Offices of Minority Health;
USA
4 National Rural Health Association; USA
5 National Business Group on Health; USA
- Draft Background Paper 13 -
Disclaimer
WCSDH/BCKGRT/13/2011
This draft background paper is one of several in a series
commissioned by the World Health Organization for the
World Conference on Social Determinants of Health, held 19-21
October 2011, in Rio de Janeiro, Brazil. The goal
of these papers is to highlight country experiences on
implementing action on social determinants of health.
Copyright on these papers remains with the authors and/or the
Regional Office of the World Health Organization
from which they have been sourced. All rights reserved. The
findings, interpretations and conclusions expressed in
this paper are entirely those of the author(s) and should not be
attributed in any manner whatsoever to the World
Health Organization.
All papers are available at the symposium website at
www.who.int/sdhconference. Correspondence for the authors
can be sent by email to [email protected]
The designations employed and the presentation of the material
in this publication do not imply the expression of
any opinion whatsoever on the part of the World Health
Organization concerning the legal status of any country,
territory, city or area or of its authorities, or concerning the
delimitation of its frontiers or boundaries. Dotted lines
on maps represent approximate border lines for which there may
not yet be full agreement. The mention of specific
companies or of certain manufacturers' products does not imply
that they are endorsed or recommended by the
World Health Organization in preference to others of a similar
nature that are not mentioned. Errors and omissions
excepted, the names of proprietary products are distinguished
by initial capital letters. The published material is
being distributed without warranty of any kind, either expressed
or implied. The responsibility for the interpretation
and use of the material lies with the reader. In no event shall the
World Health Organization be liable for damages
arising from its use.
- Draft Background Paper 13 -
1
Executive Summary
In its effort to achieve health equity, the United States joins
other countries that are also confronting
the problem of ending health disparities. Health equity is
attainment of the highest level of health for
all people. Achieving health equity requires valuing everyone
equally with focused and ongoing
societal efforts to address avoidable inequalities, historical and
contemporary injustices, and the
elimination of health and healthcare disparities.
Health disparities are persistent and pervasive in America,
affecting its racial and ethnic minorities,
other at-risk populations, and those of low socioeconomic and
educational status. The vision for a
healthier America was the force that brought together thousands
of community and government
leaders to develop the National Partnership for Action to End
Health Disparities (NPA). Although
efforts to address health equity began prior to the NPA, those
efforts were carried by specific
organizations and sectors (e.g., local health departments,
universities, health systems, philanthropy,
etc.).
Efforts to end health disparities are inherently a comprehensive
community and systems change
effort. The NPA is about change: why there should be change,
who should effect the change, and the
strategies that can be applied to implement change. The changes
needed to achieve health equity in
the United States can take place only with the cooperative effort
of individuals at all levels of public
and private enterprise. The NPA is the first national, multi -
sector, community- and partnership-driven
effort on behalf of health equity—with government leading the
way.
The development of the NPA was sponsored by the U.S.
Department of Health and Human Services
and its Office of Minority Health through a sequence of
activities that included regional meetings for
community and stakeholder leaders throughout the country, a
national public commentary period,
and numerous levels of review, analysis, and content refinement
by a range of experts. More than
2000 individuals participated on behalf of community- and
faith-based organizations; businesses;
healthcare and insurance industries; academia; city/county,
state, tribal, and federal governments;
and other sectors.
The NPA’s prime product, the National Stakeholder Strategy for
Achieving Health Equity, offers a set
of 20 community-driven strategies to end health disparities in
the United States and to achieve
- Draft Background Paper 13 -
2
health equity though collaboration and synergy. It was released
nationally on 8 April 2011
simultaneously with the HHS Action Plan to Reduce Racial and
Ethnic Health Disparities (represents
the federal commitment for health equity and a response to the
strategies recommended in the
National Stakeholder Strategy for Achieving Health Equity).
Together the two documents offer new
strategies and a mechanism for new partnerships aimed at
closing the health gap for the nation’s
racial, ethnic, and underserved communities.
Comprehensive change takes time, significant resources, and the
efforts of many partners. Beyond
financial and human capital, these efforts also require wide-
ranging coordination, transparency, and
commitment. The NPA is forging a new path for which there is
no prior roadmap. Although early in its
implementation, the NPA has already made a difference in the
way partners frame their work,
individually and collectively. Partners are beginning to use NPA
goals and, ultimately, these actions
translate into positive opportunities for communities. A key
lesson learned is that the NPA achieves a
momentum for change as it creates a national forum and
strategy for cooperation.
Problem
The United States is among the richest countries in the world,
yet disparities in health and
healthcare continue to exist for many of its vulnerable
populations. These persistent and pervasive
disparities carry a high societal burden in terms of the loss of
valuable resources (e.g., financial
capital, healthy children and families, workforce capacity and
capability, and social compassion).
Throughout its existence America has welcomed people of many
nations and cultures to its shores.
With this rich diversity comes a wide range of experience with
health and healthcare disparities.
Examples of these are outlined in Exhibit 1. These disparities
have been extensively documented
over time, most notably in the 1985 Report of the Secretary's
Task Force on Black and Minority
Health (an early and influential federal effort); the 2002
congressionally-mandated report on
healthcare disparities from the Institute of Medicine; the yearly
(since 2003) federal National
Healthcare Disparities Report and National Healthcare Quality
Report; and Healthy People 2020,
America’s master blueprint for health, among other sources.
Federal standards designate racial categories as White; African
American or Black; Asian; American
Indian or Alaska Native; and Native Hawaiian or Pacific
Islander; and ethnic categories as Hispanic
and non-Hispanic. However, these represent broad categories.
Statistically significant data are often
- Draft Background Paper 13 -
3
not available for the diversity of smaller subpopulations in the
United States. Grouping of data can
mask and significantly underestimate the health and healthcare
disparities that exist for
subpopulations. Underestimates of health or socioeconomic
status adversely affects awareness of
health disparities—with a corresponding lost opportunity to
focus on prevention, healthcare,
research, and other efforts. As a result, the populations affected
by inadequate or inaccurate data
collection continue to suffer from poorer health outcomes. It is
not only racial and ethnic minorities
that suffer from health-related disparities, but also other
underserved populations, such as those in
certain geographic areas, individuals with disabilities, LGBT
populations, and those of low
socioeconomic and educational status (see Exhibit 1).
The U.S. Department of Health and Human Services (HHS), the
public health system, the medical
care system, and the community of stakeholders have struggled
with the problem of health and
healthcare disparities for many years, in spite of their many
successes. New strategies for change
were needed and the climate for change was right. In particular:
Awareness continues to grow that
health disparities are a significant component of healthcare
costs. For example, the direct and
indirect costs of health inequalities and premature death were
estimated at $1.24 trillion between
2003 and 2006. Addressing health disparities is an obvious
point of intervention that can provide
both financial and ethical payoffs. Minority populations are
increasing in number faster than the non-
Hispanic White population and are expected to comprise 40
percent of the population by the year
2030. The adverse economic and social impact of not addressing
health inequities for minorities
costs the loss of economic and human capital. There is a
growing constituency for change as
awareness increases concerning the social determinants of
health; the lack of improvement in
health status for minorities and underserved populations; and
the financial and social consequences
of health disparities. With awareness there has grown a body of
health equity stakeholders across all
sectors (federal, state, tribal, local, community, faith-based,
non-profit, private, academic, and
business) that support appropriate policies and actions. Ongoing
advances in technology provide a
favorable climate for change. For example, many public and
private agencies are able to collect,
analyze, store, and allow public access to massive amounts of
health-related data. The expanding
adoption of social networking technology across all sectors of
American society offers new
opportunities for promoting awareness of disease prevention
and health equity messages. In 2010
President Obama signed the Patient Protection and Affordable
Care Act, which enacted
comprehensive health insurance reforms and which, among
other requirements, contains provisions
- Draft Background Paper 13 -
4
to improve the federal infrastructure for addressing minority
health concerns, the diversity of the
healthcare workforce, and others that contribute to health
equity. The 2009 Health Information
Technology for Economic and Clinical Health Act mandates
comprehensive adoption of electronic
health records.
Exhibit 1: An Overview of Exhibit 1: An Overview of Exhibit 1:
An Overview of Exhibit 1: An Overview of Health Disparities
in the United StatesHealth Disparities in the United
StatesHealth Disparities in the United StatesHealth Disparities
in the United States
Examples of Populations Experiencing DisparitiesExamples of
Populations Experiencing DisparitiesExamples of Populations
Experiencing DisparitiesExamples of Populations Experiencing
Disparities
Racial/EthnicRacial/EthnicRacial/EthnicRacial/Ethnic
African American; Asian; American
Indian or Alaska Native; Native
Hawaiian or Pacific Islander;
Hispanic
AtAtAtAt----Risk PopulationsRisk PopulationsRisk
PopulationsRisk Populations
women, infants, children,
adolescents, elderly, people with
disabilities, rural and urban
populations, low literacy individuals,
LGBT populations
Social Social Social Social Determinants Determinants
Determinants Determinants
FactorsFactorsFactorsFactors
low socioeconomic status;
low educational attainment
Examples of WellExamples of WellExamples of WellExamples
of Well----documented and Prominent Disparitidocumented and
Prominent Disparitidocumented and Prominent
Disparitidocumented and Prominent Disparitieseseses
GeneralGeneralGeneralGeneral
SpecificSpecificSpecificSpecific1111
1Except as noted, data are from sources reported in the National
Stakeholder Strategy
Disparities in HealthDisparities in HealthDisparities in
HealthDisparities in Health
infant mortality
maternal mortality
cardiovascular disease
cancer
HIV/AIDS
• Black infants die at rates 2.4 times that of White infants.
• The maternal mortality rate for Blacks is 3 times that of
Whites;
and is nearly 6 times higher for women over 35 years compared
to those under 20 years of age.
• Compared to Whites, the incidence of HIV/AIDS is higher for
Blacks, Native Hawaiians and Pacific Islanders, and Hispanics
(8.9 times, 4.0 times, 3.4 times, respectively).
• Compared to the general population deaths from tuberculosis,
alcohol, motor vehicle accidents, and diabetes are higher for
- Draft Background Paper 13 -
5
diabetes
chronic lower respiratory
diseases
viral hepatitis
chronic liver disease and
cirrhosis
kidney disease
oral health
injury deaths
violence
mental health
substance abuse
other behavioral health disorders
American Indians and Alaska Natives (6 times, 6.1 times, 3.1
times, and 2.8 times, respectively).
• Compared to adults (35 and older), youths ages 18-25 are
more
than 4 times more likely to use illicit drugs and more than 2
times more likely to binge drink alcohol.
• Disabled persons, women, children, the elderly, the homeless,
and minorities disproportionately experience exposure to
violence. Disabled youths ages 12-19 experience violence at
nearly twice the rate as those without a disability.
• The poor are 2.5 times more likely to have untreated tooth
decay
than the not poor.
• Asians, Native Hawaiians, and Pacific Islanders account for
over
half of chronic Hepatitis B cases.
• Blacks, Asians, Pacific Islanders, and Hispanics have stomach
cancer mortality rates that are 1.5 times that of Whites. Cancer
is the leading cause of death for Asians and Pacific Islanders.
Disparities in Health CareDisparities in Health CareDisparities
in Health CareDisparities in Health Care2222
ability to access care
ability to obtain quality care
health insurance coverage
2These data are from the 2010
National Healthcare Disparities
Report
• Compared with residents of large city suburbs, residents of
rural
areas had worse care for about 40% of access measures and
30% of quality measures.
• Compared to non-Hispanic Whites, Hispanics had worse care
for
83% of access measures and 56% quality measures.
• Compared to high-income individuals, the poor had worse care
for 100% of access measures and 83% quality measures.
• The poor are 4.7 times more likely to not have health
insurance
than are those with high income.
• Although 25% of Americans live in rural areas, only 10% of
doctors practice in those settings.
- Draft Background Paper 13 -
6
HealthcHealthcHealthcHealthcare Workforce Disparitiesare
Workforce Disparitiesare Workforce Disparitiesare Workforce
Disparities
minority representation in the
healthcare workforce;
workforce shortages in
geographic locations;
availability of culturally and/or
linguistically competent providers
• Only 21% of medical school graduates plan to practice in
underserved areas.
• Hispanics represent about 15% of the population but comprise
only 5% of physicians, 5-7% of nursing, dental, and medical
school students, and 4% of medical school faculty.
• Blacks represent about 13% of the population but comprise
only
3.5% of physicians, 6-7% of dental and medical school students,
and 3% of medical school faculty.
Disparities in Data CollectionDisparities in Data
CollectionDisparities in Data CollectionDisparities in Data
Collection
inadequate collection of health
and healthcare metrics by race,
ethnicity, and primary language—
especially for population
subcategories and small
populations
• Mortality rates for American Indian and Alaska Native
populations have been underestimated due to the miscoding of
race on death certificates.
• U.S.-born African Americans, and Black immigrants from
Sub-
Saharan Africa, South America and the Caribbean may be
grouped together under the category of “Black.”
• Asians, Asian sub-groups, Native Hawaiians, and Pacific
Islanders may be grouped together under the category of
“Asian”
or “Asian/Pacific Islander.”
Examples of Significant U.S. Examples of Significant U.S.
Examples of Significant U.S. Examples of Significant U.S.
Publications that Address Disparities (including those
above)Publications that Address Disparities (including those
above)Publications that Address Disparities (including those
above)Publications that Address Disparities (including those
above)
The 1985 Report of the Secretary's Task Force on Black and
Minority Health, HHS; 2002 report from the
Institute of Medicine: Unequal Treatment: Confronting Racial
and Ethnic Disparities in Health; yearly
(since 2003) National Healthcare Disparities Report and
National Healthcare Quality Report from the
Agency for Healthcare Research and Quality, HHS; 2011 report
from the Centers for Disease Control and
Prevention, HHS: Health Disparities and Inequalities; Healthy
People 2020, HHS.
- Draft Background Paper 13 -
1
In order to close the health gap for the nation’s racial, ethnic,
and underserved communities in a climate
that was ripe for change, the federal Office of Minority Health
(OMH) within HHS sponsored the
development of the National Partnership for Action to End
Health Disparities (NPA). Its goal was to
mobilize and connect individuals and organizations from across
the country to create a nation in which
all people have an equal opportunity to reach their full health
potential. Given the broad range of
disparity populations and needs within the United States, it has
become increasingly clear that
government agencies and private constituencies working alone
within their own sectors are inadequate
for solving the problem of health disparities. The driving force
of the NPA is the conviction that a
nationally-based strategy is needed—one that relies on multiple
layers of partnerships across sectors in
order to leverage resources and talent. The NPA’s strategic
importance is based on its identity as a
public/private partnership that includes the combined efforts of
governments, academia, institutions,
businesses, humanitarian and faith-based organizations, and
individuals working across the entire
spectrum of public, private, community, and individual
enterprise. The NPA is designed to address a
wide breadth of inequities. However, it does so through a
common set of goals and strategies that all of
its stakeholders can adapt to their specific situations,
partnerships, and resources.
Context
As is common throughout the world, the social determinants
that primarily contribute to America’s
health disparities are poverty; racial/ethnic minority status; and
lack of education, economic
opportunity, and access to healthcare resources. These
determinants are often related to patterns of
social disadvantage or exclusion. Thus, the NPA defines health
disparityhealth disparityhealth disparityhealth disparity as a
particular type of health
difference that is closely linked with social or economic
disadvantage. Health disparities adversely
affect groups of people who have systematically experienced
greater social and/or economic obstacles
to health and/or a clean environment based on their racial or
ethnic group; religion; socioeconomic
status; gender; age; mental health; cognitive, sensory, or
physical disability; sexual orientation;
geographic location; or other characteristics historically linked
to discrimination or exclusion. The
primary groups which the NPA focuses on are racial and ethnic
minorities, geographic populations, the
disability community, and LGBT populations —within the
context of the populations and disparities noted
in Exhibit 1. These groups were chosen based on input from the
thousands of individuals that
participated in developing the NPA.
- Draft Background Paper 13 -
2
The NPA’s five central goalsNPA’s five central goalsNPA’s
five central goalsNPA’s five central goals are are are are: 1. 1.
1. 1. Increase awarenessawarenessawarenessawareness of the
significance of health disparities, their
impact on the nation, and the actions necessary to improve
health outcomes for racial, ethnic, and
underserved populations; 2. 2. 2. 2. Strengthen and broaden
leadershipleadershipleadershipleadership for addressing health
disparities at all
levels; 3. 3. 3. 3. Improve health and healthcare outcomeshealth
and healthcare outcomeshealth and healthcare outcomeshealth
and healthcare outcomes for racial, ethnic, and underserved
populations; 4. 4. 4. 4.
Improve cultural and linguistic competencycultural and
linguistic competencycultural and linguistic competencycultural
and linguistic competency and the diversity of the health-related
workforce; and 5. 5. 5. 5.
Improve datadatadatadata availability and coordination,
utilization, and diffusion of researchresearchresearchresearch
and evaluationevaluationevaluationevaluation
outcomes. Four crosscutting, fundamental principlesFour
crosscutting, fundamental principlesFour crosscutting,
fundamental principlesFour crosscutting, fundamental principles
are central to the NPA: leadership through
community engagementcommunity engagementcommunity
engagementcommunity engagement; the value of working via
partnershipspartnershipspartnershipspartnerships, the necessity
of cultural and lcultural and lcultural and lcultural and
linguistic inguistic inguistic inguistic
competencycompetencycompetencycompetency to meet the
needs of all communities, and the requirement of
nonnonnonnon----
discriminationdiscriminationdiscriminationdiscrimination in
actions,
services, leadership, and partnerships.
The formation of the NPA stands squarely within the context of
the democratic values of the United
States. That is, policies are established and action is taken with
input from public and private
stakeholders. Governments at all levels have a role in working
for the health and well being of its
citizenry; organizations have a role; states and citizens have
rights. In a matter as critical as advancing
health equity, the NPA offers a forum for sharing ideas and
resources, an opportunity for partnerships on
behalf of strategic action, and above all, a collaborative
approach to problem solving.
OMH sponsored the planning and development of the NPA.
However, a fundamental value of the NPA is its
lack of dependency on an influx of government spending. The
expectation is that OMH and other
government agencies will act as catalysts for change by
leveraging their existing partnerships and resources.
In this way they act as models for other NPA constituencies and
partners. Partnerships emphasize the
pooling and efficient use of resources, mobilization of talents,
and use of diverse approaches in order to
avoid duplication of efforts and fragmentation of services.
Partnerships promote sharing of human and
material resources, finances, and time in order to strategically
leverage funding and talent in an era of
scarcity and limitation.
Planning
The formation of the NPA was based on the voices of nearly
2,000 leaders who overwhelmingly
supported broadening the national dialogue about health
disparities from the more traditional disease-
focused approach to a more systems-oriented approach that
addresses crosscutting, multilevel issues.
These perspectives were gathered via a multi-year, multi-
layered, community-based process that was
- Draft Background Paper 13 -
3
sponsored by OMH. This process emphasized a "bottom up"
approach. The intent was to change the
paradigm of strategy development by vesting individuals—
particularly those at the front line of fighting
health disparities—with identifying and helping to shape core
actions for a coordinated national
response. Thus one of the earliest planning activities was a
series of countrywide regional
conversations, which included “community voices” meetings,
with representatives from minority groups
and organizations, American Indian and Alaska Native tribes,
community organizations, faith-based
organizations, health care providers and organizations, state and
local public health agencies and
organizations, academia and research, and health systems. The
process continued with increasing input
from groups representing policy makers, business, rural and
border health populations and others
interested in health equity. This included analysis, input, and
content refinement from a National
Visionary Panel of experts as well as a National Consensus
Meeting for late-stage review and refinement
of content. A Federal Interagency Health Equity Team
(FIHET)Federal Interagency Health Equity Team
(FIHET)Federal Interagency Health Equity Team
(FIHET)Federal Interagency Health Equity Team (FIHET) was
established to provide guidance. Its
members are representatives of HHS and the federal
departments of Agriculture, Commerce, Defense,
Education, Housing and Urban Development, Justice, Labor,
Transportation, and Veterans Affairs, as
well as from the Environmental Protection Agency and the
Consumer Products Safety Commission. The
process also included a six-week national public comment
period.
The NPA planning period culminated with the 8 April 2011
release of the National Stakeholder Strategy
for Achieving Health Equity (“National Stakeholder Strategy”),
which provides a detailed analysis of
health and healthcare disparities and 20 strategies for common
action, each of which aligns with one of
the five NPA goals. Each of the 20 strategies has a
corresponding set of objectives, measures, and
potential data sources that, in toto, offer a starting plan of
action that can be adapted to the needs and
resources of any organization or partnership working to reduce
health disparities.
In conjunction with the launch of the National Stakeholder
Strategy, HHS simultaneously released its
first ever HHS Action Plan to Reduce Racial and Ethnic Health
Disparities (“HHS Disparities Plan”),
which will be renewed annually. The HHS Disparities Plan is a
federal response to the National
Stakeholder Strategy and a pledge of the government’s
accountability in supporting health equity. With
it, HHS broadcasts its commitment to integrated approaches,
evidence-based programs, and strong and
visible national direction for leadership among public and
private partners on behalf of health equity.
The 2011 twin launch of these complementary community and
federal documents—and their ongoing
- Draft Background Paper 13 -
4
implementation among community stakeholders nationwide and
within HHS—mark the beginning of
widespread public/private cooperation and coordination aimed
at achieving health equity.
The NPA promotes and strengthens collaboration across
multiple sectors, and at federal, regional, state,
and community levels through three components: 1) the
National Stakeholder Strategy and related
documents such as the HHS Disparities Plan; 2) Specific
Blueprints for Action (aligned with the National
Stakeholder Strategy) for selected populations and for each of
10 geographic regions; and 3) targeted
initiatives that will be undertaken by partners across the public
and private sectors in support of the
NPA.
The policy tools and organizations that will move
implementation of the National Stakeholder Strategy
include the legislative mandates of the Affordable Care Act and
other laws; the longstanding relationship
between OMH and the state offices of minority health (SOMH);
the minority health-promoting
mechanisms that already exist throughout HHS and other
government departments; partnerships with
public health entities that facilitate the engagement and
education of policymakers at the state level
(e.g., the National Conference of State Legislatures, the
Association of State and Territorial Health
Officials, the National Association of State Offices of Minority
Health); partnerships with entities that
educate the business sector to embrace health equity as a
financially profitable policy (e.g., the National
Business Group on Health); and organizations which work to
improve the health and well-being of
geographic populations (e.g., the National Rural Health
Association).
Implementation
One of the most challenging steps in achieving any significant
goal is to move from ideas to action—from
planning to implementation. Thus, the existence of the NPA
does not in and of itself lead to the
achievement of its intended outcomes. Success will be
dependent upon the ability to implement and
assess progress for the National Stakeholder Strategy; the HHS
Disparities Plan and other related
federal documents; the Blueprints for Action; and the targeted
initiatives that will be undertaken by
partners across the public and private sectors. Implementation
has been a critical concern of the NPA.
An initial implementation framework has been developed by a
diverse group of stakeholders and was
refined through the NPA development process previously
described. It is grounded in the key concepts
of leadership, ownership, partnership, capacity, and
communication. Implementation will be
operationalized through voluntary multi-sector, multi-level
councils that provide leadership, ensure
- Draft Background Paper 13 -
5
continued information flow, and galvanize action at the federal,
national, regional, state, tribal, and local
levels.
A communications plan A communications plan A
communications plan A communications plan is a key
component of implementation and evaluation. The NPA
communication
plan focuses on (1) increasing awareness among key audiences
of the significance of health disparities,
their impact on the nation, and the actions necessary to achieve
health equity; (2) helping partners
promote and address the goals by making them a priority, and
by sharing information within their
individual networks to broaden diffusion of information; (3)
ensuring cohesion in all communications
and coordination between and among the multi-sector, multi-
level councils and their partners, and
fostering effective communication and sharing of information
by creating dynamic feedback loops
between the councils to share relevant activities, policies,
emerging issues, priorities, and
evaluation/best practices.
NPA implementation is supported in part by OMH and several
contracts managed by OMH to assist with
coordinating, monitoring, and sustaining the NPA. Support
includes assistance with:
•
ImplementationImplementationImplementationImplementation
—coordinating and facilitating council meetings, consulting
with leaders and
experts, engaging communities, developing content for
Blueprints for Action, producing tools and
materials, working with partners to ensure connection and
integration with implementation actions
or plans, building partnerships, and providing implementation
capacity building support.
•
CommunicationsCommunicationsCommunicationsCommunicatio
ns—crafting and integrating NPA messages for various
audiences, developing
communication tools, and helping disseminate NPA information
to key audiences in various
formats as a means for sharing knowledge about activities,
emerging issues, priorities, and
evaluation/best practices.
• EvaluationEvaluationEvaluationEvaluation—managing and
monitoring evaluation activities to ensure that partners connect
and
contribute to the NPA evaluation; providing capacity building
support to communities; and
negotiating data use and reporting with agencies who manage
data systems relevant to the NPA.
Initial implementation will roll out in stages. Phase IPhase
IPhase IPhase I involves the activities of the FIHET, FIHET
subcommittees, and National Partners. Phase IIPhase IIPhase
IIPhase II involves the activities of Regional Health Equity
Councils, state offices of minority health, and expanded
national partnerships with businesses and other
communities. Phase IIIPhase IIIPhase IIIPhase III involves
targeted multi-agency initiatives to minimize duplication and
increase
effectiveness. Current NPA implementation activities include
the following:
- Draft Background Paper 13 -
6
Phase1Phase1Phase1Phase1––––FIHETFIHETFIHETFIHET
includes representation from 12 federal agencies as described
above. The purpose of
FIHET is to (1) identify opportunities for federal collaboration,
partnership, coordination, and/or action
on efforts that are relevant to the NPA; and (2) provide
leadership and guidance for national, regional,
state, and local efforts that address health equity. The FIHET
played a critical role in providing feedback
on the NPA’s development. Moving into the implementation
phase, FIHET has established five
subcommittees to develop implementation recommendations
linked to the five NPA goals. Each
subcommittee has developed work plans outlining its priorities,
associated strategies that connect the
work of federal agencies, action steps; as well as timelines and
intended outcomes for each priority.
Phase1Phase1Phase1Phase1––––National PartnersNational
PartnersNational PartnersNational Partners work with the NPA
to leverage resources, expand its reach and spheres of
influence, infuse NPA goals and strategies into organizational
policies and practices, and share stories
and successes with their broad constituencies. National partners
will include community- and faith-
based organizations, professional societies, government
agencies, national non-profit organizations,
advocacy groups, foundations, corporations, businesses of all
sizes, industry groups, and colleges and
universities. For example,
• The National Conference of State Legislatures (NCSL) The
National Conference of State Legislatures (NCSL) The National
Conference of State Legislatures (NCSL) The National
Conference of State Legislatures (NCSL) is a bipartisan
organization that serves the
legislators and legislative staff of the nation's 50 states, its
commonwealths and territories. NCSL
works with OMH to help state legislators understand issues
related to health disparities and how
specific policies either narrow or widen disparities in health
care for racial and ethnic minorities.
• The Association of State and Territorial HeThe Association of
State and Territorial HeThe Association of State and Territorial
HeThe Association of State and Territorial Health Officials
(ASTHO) alth Officials (ASTHO) alth Officials (ASTHO) alth
Officials (ASTHO) recognizes that progress in
improving the health of minority populations will require that
states have access to information on
effective practices as well as resources to assist in the
implementation of effective public health
policies and programs. ASTHO aims to fill these knowledge
gaps, strengthen state leadership, and
improve health disparities efforts through various activities
under the NPA.
• The National Association of State Offices of Minority Health
(NASOMH)The National Association of State Offices of
Minority Health (NASOMH)The National Association of State
Offices of Minority Health (NASOMH)The National
Association of State Offices of Minority Health (NASOMH)
promotes and protects the
health of communities of color, and tribal organizations and
nations. Its NPA activities include
technical assistance for SOMHs in engaging communities on
NPA actions, building awareness, and
incorporating or aligning state health disparity and/or health
equity plans with NPA goals.
- Draft Background Paper 13 -
7
• National Business Group on Health (NBGH)National Business
Group on Health (NBGH)National Business Group on Health
(NBGH)National Business Group on Health (NBGH) is a
national, nonprofit devoted exclusively to finding
innovative and forward-thinking business solutions to the
nation’s most important healthcare
challenges. As a NPA partner, NBGH is working to make the
case to employers that addressing
health disparities is a good financial and business decision.
• The The The The National Rural Health AssociationNational
Rural Health AssociationNational Rural Health
AssociationNational Rural Health Association (NRHA) (NRHA)
(NRHA) (NRHA) is a national nonprofit that provides
leadership on
rural health issues. Its role in the NPA is as a bridge connecting
minority and rural health
constituencies and needs, building awareness, and addressing
actions for border populations.
Phase IIPhase IIPhase IIPhase II————10 Regional Health
Equity Councils10 Regional Health Equity Councils10 Regional
Health Equity Councils10 Regional Health Equity Councils are
being launched that will focus on groups of states
nationwide. Initial planning meetings were held in four
geographic regions prior to the launch of the NPA.
The councils will address health disparity improvement actions
for their geographic areas and work to
leverage resources, infuse NPA goals and strategies into
policies and practices, and share stories and
successes with broad constituencies. The councils include
individuals from the public, nonprofit, and
private sectors and they represent communities experiencing
health disparities; state and local
government agencies; tribes and tribal organizations; healthcare
providers and systems; health plans;
businesses; academic and research institutions; foundations; and
other organizations who focus on
specific determinants of health (e.g., environmental justice,
housing, transportation, education, etc.).
Phase IIPhase IIPhase IIPhase II————State Offices of
Minority Health (SOMH) State Offices of Minority Health
(SOMH) State Offices of Minority Health (SOMH) State Offices
of Minority Health (SOMH) are actively engaging communities
through periodic
meetings; developing strategic partnerships, mobilizing
networks; improving awareness and
communications through different media outlets; and leading
states’ efforts in updating health disparity
or health equity plans so that they align with the NPA. The
SOMHs come together during monthly
conference calls to update each other on progress, address
challenges, share lessons learned, and
consider collective actions.
Evaluation
The NPA Evaluation Plan provides a roadmap for determining
the effectiveness of NPA strategies and
actions. It describes the overall approach, key indicators and
measures, data sources, and potential
data collection methods. The goal of the evaluation is to ensure
the integration and penetration of NPA
efforts across sectors (e.g., education, housing, environmental
health) and across levels (i.e., federal,
national, regional, state, tribal, and community). A logic model
was created by a team of expert advisors
to illustrate the implementation pathway and anticipated
outcomes of the NPA. The model is based on
- Draft Background Paper 13 -
8
the assumption that observable changes in the way public and
private organizations work across sectors
to address the social determinants of health are more likely to
occur initially than are observable
population-level outcomes. Therefore, the initial focus for
evaluation is to determine whether (1)
organizational and structural changes have actually been made
on behalf of health equity; (2) specific
actions have been taken that align with the NPA’s five goals
and 20 strategies; (3) public awareness and
understanding about social determinants has increased; (4)
policy, systems, and other multi-level
changes have been initiated; (5) there is an increase in
communities’ capacities to address health
disparities through the use of data for decisionmaking; and (6)
whether promising practices can be
identified. Evaluations will also consider the feasibility of
developing and using a social determinants
health equity index to assess how well the nation is progressing
towards improved health outcomes.
Even with an optimal social determinants index, it will take
several years before observable changes can
be expected.
The evaluation plan has identified initial optimal indicators and
measures. Some of these measures are
already available; others will need to be developed. To the
degree possible, evaluation teams will
coordinate NPA evaluations with those of other federal entities
and with NPA partners in order to
minimize duplication and to build on existing data analyses and
sources. Evaluation teams will work with
OMH leadership to facilitate the development of data-sharing
agreements and protocols. Current
proposed indicators are as follows:
- Draft Background Paper 13 -
9
Exhibit 2: Current Proposed Evaluation IndicatorsExhibit 2:
Current Proposed Evaluation IndicatorsExhibit 2: Current
Proposed Evaluation IndicatorsExhibit 2: Current Proposed
Evaluation Indicators
Infrastructure and Partnerships
Productive and effective health equity councils, including the
Federal Interagency Health Equity
Team and the national, regional, state, tribal and community
health equity councils
Productive and effective NPA Partnerships (e.g., Association of
State and Territorial Health Officials,
National Conference of State Legislatures, National Business
Group on Health, National Association
of State Offices of Minority Health)
Vertical (e.g., between state and region) and horizontal (e.g.,
among states or regions) alignment
among national, regional, state, tribal, and local efforts
Actions
Multi-sector and multi-level actions
Goal attainment
Alignment between actions and results
Capacity for implementing strategies to end health disparities
Public Awareness and Understanding
Awareness of NPA
Awareness of health disparities and understanding of social
determinants
News coverage from print, broadcast, and internet news sources
on health-related issues affecting
underserved and racial and ethnic communities (including
mainstream and selected racial and
ethnic print news sources)
Policy, Systems, and Other MultiPolicy, Systems, and Other
MultiPolicy, Systems, and Other MultiPolicy, Systems, and
Other Multi----level Changelevel Changelevel Changelevel
Changessss
Influence of NPA on its partners
Inclusion of health disparities or health equity concepts and
language (e.g., social determinants) in
mainstream institutions and among broad leadership
Influence of NPA on local, state, and national healthcare-related
policies
Influence of NPA on local, state, and national policies,
procedures, and practices that address the
social determinants of health
- Draft Background Paper 13 -
10
Evaluators will select a final list of indicators and measures, as
well as the sample of regions, states,
and organizations that will be included in the initial evaluation.
In general, data collection activities can
be summarized into the following types:
• Surveys of the FIHET, Regional Health Equity Councils, and
NPA partners;
• Review and analysis of the goals and strategies implemented
by the FIHET, Regional Health
Equity Councils, and NPA partners;
• Content analysis of NPA partners’ programs, agendas,
materials, plans, etc.;
• Interviews with key informants at the federal and national
levels and in the regions, states, and
tribes that are part of the sample.
Cross-case study method will be used to analyze the data. This
method allows for comparisons across
and within selected regions, states, and communities, as well as
the combined use of qualitative and
quantitative methods. The findings will be compiled into case
studies. Each case study will tell the story
of what transpired in each of the sample geographic units and
will provide insight into the context and
circumstances under which changes did or did not take place.
Each case study will, in turn, contribute to
a national, in-depth case study on the NPA’s effectiveness.
Time-series presentations of data will also be
conducted in order to show changes.
The evaluation team will submit semiannual reports on its
progress, and annual reports that will
contribute to the OMH reports to the U.S. Congress. Annual
reports will also be provided to the FIHET,
Regional Health Equity Councils, NPA partners, and the
implementation and communications teams.
Reports will be posted on the NPA website and made available
and accessible to the public. The
evaluation team will facilitate a meeting to reflect and discuss
the findings with OMH leadership and
staff, the implementation teams, and the communications teams.
Meetings will focus on the lessons
learned and the implications for iterative strategy improvement
and implementation.
Follow-up and lessons learned
Efforts to end health disparities are inherently a comprehensive
community and systems change effort.
The NPA is about change: why there should be change, who
should effect the change, and the strategies
- Draft Background Paper 13 -
11
that can be applied to implement change. The changes needed
can take place only with the cooperative
effort of individuals at all levels of public and private
enterprise.
Managing and coordinating the magnitude of planning and
implementation activities has been one of
the greatest challenges of the NPA. That challenge continues as
the NPA deliberately plans for further
growth with phased and monitored expansion of the number of
NPA partners and activities. Past
experiences in driving a health equity agenda underscore the
lesson that comprehensive efforts take
time, significant resources, and the efforts of many partners.
Beyond financial and human capital, these
efforts also require significant coordination, transparency, and
commitment. The growth of the U.S.
knowledge base, constituency, and programs for health equity in
the past few decades has formed the
foundation necessary to initiate and sustain the NPA.
Individuals across sectors have committed to
participate in NPA activities because of their passion and
commitment to its vision and goals.
The NPA represents a grassroots effort to form strategic
partnerships and engage communities and
organizations on behalf of health equity. As a grassroots effort,
all partners have had to “own” the NPA
in order for it to survive and thrive. Continued progress is
dependent on success in transforming the
quality and commitment of stakeholder partnerships. Ideally,
individuals and organizations will expand
their sharing of resources and spheres of cooperation beyond
customary relationships to include
partners that can enhance mission capacity and value in new and
effective ways. The holistic approach
of the NPA to integrate implementation, communication and
evaluation activities supports participants
as they unite to prioritize common goals, share successful
strategies, and move from planning to action.
The objective is to advance implementation, communication and
evaluation at a pace that maintains
their coordination and alignment while also maintaining the
engagement of all stakeholders.
The NPA is forging a new path for which there is no prior
roadmap. Lessons are learned as actions are
planned and executed. Partners and experts are continually
encouraged to address new and emerging
opportunities. An important lesson has been that an
understanding of the social determinants of health
does not in itself bring expertise for creating change or forming
new relationships and partnerships.
Thus, capacity-building opportunities and tools (e.g.,
educational webinars, targeted messages, and
access to experts for consultation, etc.) to facilitate effective
participation are being developed.
Although early in its implementation, the NPA has already made
a difference in the way partners frame
their work, individually and collectively. There is evidence that
FIHET member agencies are beginning to
- Draft Background Paper 13 -
12
use the NPA goals to develop priorities and scope of activities,
which translates into positive
opportunities for communities. In addition, FIHET members
have consistently engaged and recruited
others to join the NPA. Elsewhere there has been an emerging
pattern among organizations to work
collaboratively and strategically toward common goals. NPA
partners are increasing their knowledge
about disparities, public/private sector infrastructure and
resources for addressing disparities, and how
health equity efforts can and should be integrated into the
broader national dialogue. A key lesson
learned is that the NPA achieves a momentum for change as it
creates a national forum and strategy for
cooperation.
- Draft Background Paper 13 -
www.who.int/social_determinants/www.who.int/social_determin
ants/www.who.int/social_determinants/www.who.int/social_det
erminants/
- Background Paper 13 - A national partnership f

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- Background Paper 13 - A national partnership f

  • 1. - Background Paper 13 - A national partnership for acA national partnership for acA national partnership for acA national partnership for action to tion to tion to tion to end health dend health dend health dend health disparities in the United Statesisparities in the United Statesisparities in the United Statesisparities in the United States Mirtha R. Beadle 1 Garth N. Graham 1 Paul E. Jarris 2 Carlessia A. Hussein 3 Alan Morgan 4 Ron Finch 5 1 Office of Minority Health, U.S. Department of Health and
  • 2. Human Services 2 Association of State and Territorial Health Officials; USA 3 National Association of State Offices of Minority Health; USA 4 National Rural Health Association; USA 5 National Business Group on Health; USA - Draft Background Paper 13 - Disclaimer WCSDH/BCKGRT/13/2011
  • 3. This draft background paper is one of several in a series commissioned by the World Health Organization for the World Conference on Social Determinants of Health, held 19-21 October 2011, in Rio de Janeiro, Brazil. The goal of these papers is to highlight country experiences on implementing action on social determinants of health. Copyright on these papers remains with the authors and/or the Regional Office of the World Health Organization from which they have been sourced. All rights reserved. The findings, interpretations and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner whatsoever to the World Health Organization. All papers are available at the symposium website at www.who.int/sdhconference. Correspondence for the authors can be sent by email to [email protected] The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific
  • 4. companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. - Draft Background Paper 13 - 1 Executive Summary In its effort to achieve health equity, the United States joins other countries that are also confronting the problem of ending health disparities. Health equity is attainment of the highest level of health for all people. Achieving health equity requires valuing everyone
  • 5. equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and healthcare disparities. Health disparities are persistent and pervasive in America, affecting its racial and ethnic minorities, other at-risk populations, and those of low socioeconomic and educational status. The vision for a healthier America was the force that brought together thousands of community and government leaders to develop the National Partnership for Action to End Health Disparities (NPA). Although efforts to address health equity began prior to the NPA, those efforts were carried by specific organizations and sectors (e.g., local health departments, universities, health systems, philanthropy, etc.). Efforts to end health disparities are inherently a comprehensive community and systems change effort. The NPA is about change: why there should be change, who should effect the change, and the strategies that can be applied to implement change. The changes needed to achieve health equity in
  • 6. the United States can take place only with the cooperative effort of individuals at all levels of public and private enterprise. The NPA is the first national, multi - sector, community- and partnership-driven effort on behalf of health equity—with government leading the way. The development of the NPA was sponsored by the U.S. Department of Health and Human Services and its Office of Minority Health through a sequence of activities that included regional meetings for community and stakeholder leaders throughout the country, a national public commentary period, and numerous levels of review, analysis, and content refinement by a range of experts. More than 2000 individuals participated on behalf of community- and faith-based organizations; businesses; healthcare and insurance industries; academia; city/county, state, tribal, and federal governments; and other sectors. The NPA’s prime product, the National Stakeholder Strategy for Achieving Health Equity, offers a set of 20 community-driven strategies to end health disparities in the United States and to achieve
  • 7. - Draft Background Paper 13 - 2 health equity though collaboration and synergy. It was released nationally on 8 April 2011 simultaneously with the HHS Action Plan to Reduce Racial and Ethnic Health Disparities (represents the federal commitment for health equity and a response to the strategies recommended in the National Stakeholder Strategy for Achieving Health Equity). Together the two documents offer new strategies and a mechanism for new partnerships aimed at closing the health gap for the nation’s racial, ethnic, and underserved communities. Comprehensive change takes time, significant resources, and the efforts of many partners. Beyond financial and human capital, these efforts also require wide- ranging coordination, transparency, and commitment. The NPA is forging a new path for which there is no prior roadmap. Although early in its implementation, the NPA has already made a difference in the way partners frame their work,
  • 8. individually and collectively. Partners are beginning to use NPA goals and, ultimately, these actions translate into positive opportunities for communities. A key lesson learned is that the NPA achieves a momentum for change as it creates a national forum and strategy for cooperation. Problem The United States is among the richest countries in the world, yet disparities in health and healthcare continue to exist for many of its vulnerable populations. These persistent and pervasive disparities carry a high societal burden in terms of the loss of valuable resources (e.g., financial capital, healthy children and families, workforce capacity and capability, and social compassion). Throughout its existence America has welcomed people of many nations and cultures to its shores. With this rich diversity comes a wide range of experience with health and healthcare disparities. Examples of these are outlined in Exhibit 1. These disparities have been extensively documented over time, most notably in the 1985 Report of the Secretary's Task Force on Black and Minority
  • 9. Health (an early and influential federal effort); the 2002 congressionally-mandated report on healthcare disparities from the Institute of Medicine; the yearly (since 2003) federal National Healthcare Disparities Report and National Healthcare Quality Report; and Healthy People 2020, America’s master blueprint for health, among other sources. Federal standards designate racial categories as White; African American or Black; Asian; American Indian or Alaska Native; and Native Hawaiian or Pacific Islander; and ethnic categories as Hispanic and non-Hispanic. However, these represent broad categories. Statistically significant data are often - Draft Background Paper 13 - 3 not available for the diversity of smaller subpopulations in the United States. Grouping of data can mask and significantly underestimate the health and healthcare disparities that exist for subpopulations. Underestimates of health or socioeconomic
  • 10. status adversely affects awareness of health disparities—with a corresponding lost opportunity to focus on prevention, healthcare, research, and other efforts. As a result, the populations affected by inadequate or inaccurate data collection continue to suffer from poorer health outcomes. It is not only racial and ethnic minorities that suffer from health-related disparities, but also other underserved populations, such as those in certain geographic areas, individuals with disabilities, LGBT populations, and those of low socioeconomic and educational status (see Exhibit 1). The U.S. Department of Health and Human Services (HHS), the public health system, the medical care system, and the community of stakeholders have struggled with the problem of health and healthcare disparities for many years, in spite of their many successes. New strategies for change were needed and the climate for change was right. In particular: Awareness continues to grow that health disparities are a significant component of healthcare costs. For example, the direct and indirect costs of health inequalities and premature death were estimated at $1.24 trillion between
  • 11. 2003 and 2006. Addressing health disparities is an obvious point of intervention that can provide both financial and ethical payoffs. Minority populations are increasing in number faster than the non- Hispanic White population and are expected to comprise 40 percent of the population by the year 2030. The adverse economic and social impact of not addressing health inequities for minorities costs the loss of economic and human capital. There is a growing constituency for change as awareness increases concerning the social determinants of health; the lack of improvement in health status for minorities and underserved populations; and the financial and social consequences of health disparities. With awareness there has grown a body of health equity stakeholders across all sectors (federal, state, tribal, local, community, faith-based, non-profit, private, academic, and business) that support appropriate policies and actions. Ongoing advances in technology provide a favorable climate for change. For example, many public and private agencies are able to collect, analyze, store, and allow public access to massive amounts of health-related data. The expanding
  • 12. adoption of social networking technology across all sectors of American society offers new opportunities for promoting awareness of disease prevention and health equity messages. In 2010 President Obama signed the Patient Protection and Affordable Care Act, which enacted comprehensive health insurance reforms and which, among other requirements, contains provisions - Draft Background Paper 13 - 4 to improve the federal infrastructure for addressing minority health concerns, the diversity of the healthcare workforce, and others that contribute to health equity. The 2009 Health Information Technology for Economic and Clinical Health Act mandates comprehensive adoption of electronic health records. Exhibit 1: An Overview of Exhibit 1: An Overview of Exhibit 1: An Overview of Exhibit 1: An Overview of Health Disparities in the United StatesHealth Disparities in the United
  • 13. StatesHealth Disparities in the United StatesHealth Disparities in the United States Examples of Populations Experiencing DisparitiesExamples of Populations Experiencing DisparitiesExamples of Populations Experiencing DisparitiesExamples of Populations Experiencing Disparities Racial/EthnicRacial/EthnicRacial/EthnicRacial/Ethnic African American; Asian; American Indian or Alaska Native; Native Hawaiian or Pacific Islander; Hispanic AtAtAtAt----Risk PopulationsRisk PopulationsRisk PopulationsRisk Populations women, infants, children, adolescents, elderly, people with disabilities, rural and urban populations, low literacy individuals, LGBT populations Social Social Social Social Determinants Determinants Determinants Determinants FactorsFactorsFactorsFactors
  • 14. low socioeconomic status; low educational attainment Examples of WellExamples of WellExamples of WellExamples of Well----documented and Prominent Disparitidocumented and Prominent Disparitidocumented and Prominent Disparitidocumented and Prominent Disparitieseseses GeneralGeneralGeneralGeneral SpecificSpecificSpecificSpecific1111 1Except as noted, data are from sources reported in the National Stakeholder Strategy Disparities in HealthDisparities in HealthDisparities in HealthDisparities in Health infant mortality maternal mortality cardiovascular disease cancer HIV/AIDS • Black infants die at rates 2.4 times that of White infants. • The maternal mortality rate for Blacks is 3 times that of Whites;
  • 15. and is nearly 6 times higher for women over 35 years compared to those under 20 years of age. • Compared to Whites, the incidence of HIV/AIDS is higher for Blacks, Native Hawaiians and Pacific Islanders, and Hispanics (8.9 times, 4.0 times, 3.4 times, respectively). • Compared to the general population deaths from tuberculosis, alcohol, motor vehicle accidents, and diabetes are higher for - Draft Background Paper 13 - 5 diabetes chronic lower respiratory diseases viral hepatitis chronic liver disease and cirrhosis kidney disease
  • 16. oral health injury deaths violence mental health substance abuse other behavioral health disorders American Indians and Alaska Natives (6 times, 6.1 times, 3.1 times, and 2.8 times, respectively). • Compared to adults (35 and older), youths ages 18-25 are more than 4 times more likely to use illicit drugs and more than 2 times more likely to binge drink alcohol. • Disabled persons, women, children, the elderly, the homeless, and minorities disproportionately experience exposure to violence. Disabled youths ages 12-19 experience violence at nearly twice the rate as those without a disability. • The poor are 2.5 times more likely to have untreated tooth decay than the not poor.
  • 17. • Asians, Native Hawaiians, and Pacific Islanders account for over half of chronic Hepatitis B cases. • Blacks, Asians, Pacific Islanders, and Hispanics have stomach cancer mortality rates that are 1.5 times that of Whites. Cancer is the leading cause of death for Asians and Pacific Islanders. Disparities in Health CareDisparities in Health CareDisparities in Health CareDisparities in Health Care2222 ability to access care ability to obtain quality care health insurance coverage 2These data are from the 2010 National Healthcare Disparities Report • Compared with residents of large city suburbs, residents of rural areas had worse care for about 40% of access measures and 30% of quality measures. • Compared to non-Hispanic Whites, Hispanics had worse care
  • 18. for 83% of access measures and 56% quality measures. • Compared to high-income individuals, the poor had worse care for 100% of access measures and 83% quality measures. • The poor are 4.7 times more likely to not have health insurance than are those with high income. • Although 25% of Americans live in rural areas, only 10% of doctors practice in those settings. - Draft Background Paper 13 - 6 HealthcHealthcHealthcHealthcare Workforce Disparitiesare Workforce Disparitiesare Workforce Disparitiesare Workforce Disparities minority representation in the healthcare workforce; workforce shortages in
  • 19. geographic locations; availability of culturally and/or linguistically competent providers • Only 21% of medical school graduates plan to practice in underserved areas. • Hispanics represent about 15% of the population but comprise only 5% of physicians, 5-7% of nursing, dental, and medical school students, and 4% of medical school faculty. • Blacks represent about 13% of the population but comprise only 3.5% of physicians, 6-7% of dental and medical school students, and 3% of medical school faculty. Disparities in Data CollectionDisparities in Data CollectionDisparities in Data CollectionDisparities in Data Collection inadequate collection of health and healthcare metrics by race, ethnicity, and primary language— especially for population subcategories and small
  • 20. populations • Mortality rates for American Indian and Alaska Native populations have been underestimated due to the miscoding of race on death certificates. • U.S.-born African Americans, and Black immigrants from Sub- Saharan Africa, South America and the Caribbean may be grouped together under the category of “Black.” • Asians, Asian sub-groups, Native Hawaiians, and Pacific Islanders may be grouped together under the category of “Asian” or “Asian/Pacific Islander.” Examples of Significant U.S. Examples of Significant U.S. Examples of Significant U.S. Examples of Significant U.S. Publications that Address Disparities (including those above)Publications that Address Disparities (including those above)Publications that Address Disparities (including those above)Publications that Address Disparities (including those above) The 1985 Report of the Secretary's Task Force on Black and Minority Health, HHS; 2002 report from the Institute of Medicine: Unequal Treatment: Confronting Racial and Ethnic Disparities in Health; yearly
  • 21. (since 2003) National Healthcare Disparities Report and National Healthcare Quality Report from the Agency for Healthcare Research and Quality, HHS; 2011 report from the Centers for Disease Control and Prevention, HHS: Health Disparities and Inequalities; Healthy People 2020, HHS. - Draft Background Paper 13 - 1 In order to close the health gap for the nation’s racial, ethnic, and underserved communities in a climate that was ripe for change, the federal Office of Minority Health (OMH) within HHS sponsored the development of the National Partnership for Action to End Health Disparities (NPA). Its goal was to mobilize and connect individuals and organizations from across the country to create a nation in which all people have an equal opportunity to reach their full health potential. Given the broad range of disparity populations and needs within the United States, it has become increasingly clear that
  • 22. government agencies and private constituencies working alone within their own sectors are inadequate for solving the problem of health disparities. The driving force of the NPA is the conviction that a nationally-based strategy is needed—one that relies on multiple layers of partnerships across sectors in order to leverage resources and talent. The NPA’s strategic importance is based on its identity as a public/private partnership that includes the combined efforts of governments, academia, institutions, businesses, humanitarian and faith-based organizations, and individuals working across the entire spectrum of public, private, community, and individual enterprise. The NPA is designed to address a wide breadth of inequities. However, it does so through a common set of goals and strategies that all of its stakeholders can adapt to their specific situations, partnerships, and resources. Context As is common throughout the world, the social determinants that primarily contribute to America’s health disparities are poverty; racial/ethnic minority status; and lack of education, economic
  • 23. opportunity, and access to healthcare resources. These determinants are often related to patterns of social disadvantage or exclusion. Thus, the NPA defines health disparityhealth disparityhealth disparityhealth disparity as a particular type of health difference that is closely linked with social or economic disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater social and/or economic obstacles to health and/or a clean environment based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation; geographic location; or other characteristics historically linked to discrimination or exclusion. The primary groups which the NPA focuses on are racial and ethnic minorities, geographic populations, the disability community, and LGBT populations —within the context of the populations and disparities noted in Exhibit 1. These groups were chosen based on input from the thousands of individuals that participated in developing the NPA.
  • 24. - Draft Background Paper 13 - 2 The NPA’s five central goalsNPA’s five central goalsNPA’s five central goalsNPA’s five central goals are are are are: 1. 1. 1. 1. Increase awarenessawarenessawarenessawareness of the significance of health disparities, their impact on the nation, and the actions necessary to improve health outcomes for racial, ethnic, and underserved populations; 2. 2. 2. 2. Strengthen and broaden leadershipleadershipleadershipleadership for addressing health disparities at all levels; 3. 3. 3. 3. Improve health and healthcare outcomeshealth and healthcare outcomeshealth and healthcare outcomeshealth and healthcare outcomes for racial, ethnic, and underserved populations; 4. 4. 4. 4. Improve cultural and linguistic competencycultural and linguistic competencycultural and linguistic competencycultural and linguistic competency and the diversity of the health-related workforce; and 5. 5. 5. 5. Improve datadatadatadata availability and coordination, utilization, and diffusion of researchresearchresearchresearch and evaluationevaluationevaluationevaluation outcomes. Four crosscutting, fundamental principlesFour crosscutting, fundamental principlesFour crosscutting,
  • 25. fundamental principlesFour crosscutting, fundamental principles are central to the NPA: leadership through community engagementcommunity engagementcommunity engagementcommunity engagement; the value of working via partnershipspartnershipspartnershipspartnerships, the necessity of cultural and lcultural and lcultural and lcultural and linguistic inguistic inguistic inguistic competencycompetencycompetencycompetency to meet the needs of all communities, and the requirement of nonnonnonnon---- discriminationdiscriminationdiscriminationdiscrimination in actions, services, leadership, and partnerships. The formation of the NPA stands squarely within the context of the democratic values of the United States. That is, policies are established and action is taken with input from public and private stakeholders. Governments at all levels have a role in working for the health and well being of its citizenry; organizations have a role; states and citizens have rights. In a matter as critical as advancing health equity, the NPA offers a forum for sharing ideas and resources, an opportunity for partnerships on behalf of strategic action, and above all, a collaborative approach to problem solving. OMH sponsored the planning and development of the NPA.
  • 26. However, a fundamental value of the NPA is its lack of dependency on an influx of government spending. The expectation is that OMH and other government agencies will act as catalysts for change by leveraging their existing partnerships and resources. In this way they act as models for other NPA constituencies and partners. Partnerships emphasize the pooling and efficient use of resources, mobilization of talents, and use of diverse approaches in order to avoid duplication of efforts and fragmentation of services. Partnerships promote sharing of human and material resources, finances, and time in order to strategically leverage funding and talent in an era of scarcity and limitation. Planning The formation of the NPA was based on the voices of nearly 2,000 leaders who overwhelmingly supported broadening the national dialogue about health disparities from the more traditional disease- focused approach to a more systems-oriented approach that addresses crosscutting, multilevel issues. These perspectives were gathered via a multi-year, multi- layered, community-based process that was
  • 27. - Draft Background Paper 13 - 3 sponsored by OMH. This process emphasized a "bottom up" approach. The intent was to change the paradigm of strategy development by vesting individuals— particularly those at the front line of fighting health disparities—with identifying and helping to shape core actions for a coordinated national response. Thus one of the earliest planning activities was a series of countrywide regional conversations, which included “community voices” meetings, with representatives from minority groups and organizations, American Indian and Alaska Native tribes, community organizations, faith-based organizations, health care providers and organizations, state and local public health agencies and organizations, academia and research, and health systems. The process continued with increasing input from groups representing policy makers, business, rural and border health populations and others
  • 28. interested in health equity. This included analysis, input, and content refinement from a National Visionary Panel of experts as well as a National Consensus Meeting for late-stage review and refinement of content. A Federal Interagency Health Equity Team (FIHET)Federal Interagency Health Equity Team (FIHET)Federal Interagency Health Equity Team (FIHET)Federal Interagency Health Equity Team (FIHET) was established to provide guidance. Its members are representatives of HHS and the federal departments of Agriculture, Commerce, Defense, Education, Housing and Urban Development, Justice, Labor, Transportation, and Veterans Affairs, as well as from the Environmental Protection Agency and the Consumer Products Safety Commission. The process also included a six-week national public comment period. The NPA planning period culminated with the 8 April 2011 release of the National Stakeholder Strategy for Achieving Health Equity (“National Stakeholder Strategy”), which provides a detailed analysis of health and healthcare disparities and 20 strategies for common action, each of which aligns with one of the five NPA goals. Each of the 20 strategies has a corresponding set of objectives, measures, and
  • 29. potential data sources that, in toto, offer a starting plan of action that can be adapted to the needs and resources of any organization or partnership working to reduce health disparities. In conjunction with the launch of the National Stakeholder Strategy, HHS simultaneously released its first ever HHS Action Plan to Reduce Racial and Ethnic Health Disparities (“HHS Disparities Plan”), which will be renewed annually. The HHS Disparities Plan is a federal response to the National Stakeholder Strategy and a pledge of the government’s accountability in supporting health equity. With it, HHS broadcasts its commitment to integrated approaches, evidence-based programs, and strong and visible national direction for leadership among public and private partners on behalf of health equity. The 2011 twin launch of these complementary community and federal documents—and their ongoing - Draft Background Paper 13 - 4
  • 30. implementation among community stakeholders nationwide and within HHS—mark the beginning of widespread public/private cooperation and coordination aimed at achieving health equity. The NPA promotes and strengthens collaboration across multiple sectors, and at federal, regional, state, and community levels through three components: 1) the National Stakeholder Strategy and related documents such as the HHS Disparities Plan; 2) Specific Blueprints for Action (aligned with the National Stakeholder Strategy) for selected populations and for each of 10 geographic regions; and 3) targeted initiatives that will be undertaken by partners across the public and private sectors in support of the NPA. The policy tools and organizations that will move implementation of the National Stakeholder Strategy include the legislative mandates of the Affordable Care Act and other laws; the longstanding relationship between OMH and the state offices of minority health (SOMH); the minority health-promoting mechanisms that already exist throughout HHS and other government departments; partnerships with public health entities that facilitate the engagement and
  • 31. education of policymakers at the state level (e.g., the National Conference of State Legislatures, the Association of State and Territorial Health Officials, the National Association of State Offices of Minority Health); partnerships with entities that educate the business sector to embrace health equity as a financially profitable policy (e.g., the National Business Group on Health); and organizations which work to improve the health and well-being of geographic populations (e.g., the National Rural Health Association). Implementation One of the most challenging steps in achieving any significant goal is to move from ideas to action—from planning to implementation. Thus, the existence of the NPA does not in and of itself lead to the achievement of its intended outcomes. Success will be dependent upon the ability to implement and assess progress for the National Stakeholder Strategy; the HHS Disparities Plan and other related federal documents; the Blueprints for Action; and the targeted initiatives that will be undertaken by partners across the public and private sectors. Implementation has been a critical concern of the NPA.
  • 32. An initial implementation framework has been developed by a diverse group of stakeholders and was refined through the NPA development process previously described. It is grounded in the key concepts of leadership, ownership, partnership, capacity, and communication. Implementation will be operationalized through voluntary multi-sector, multi-level councils that provide leadership, ensure - Draft Background Paper 13 - 5 continued information flow, and galvanize action at the federal, national, regional, state, tribal, and local levels. A communications plan A communications plan A communications plan A communications plan is a key component of implementation and evaluation. The NPA communication plan focuses on (1) increasing awareness among key audiences of the significance of health disparities, their impact on the nation, and the actions necessary to achieve
  • 33. health equity; (2) helping partners promote and address the goals by making them a priority, and by sharing information within their individual networks to broaden diffusion of information; (3) ensuring cohesion in all communications and coordination between and among the multi-sector, multi- level councils and their partners, and fostering effective communication and sharing of information by creating dynamic feedback loops between the councils to share relevant activities, policies, emerging issues, priorities, and evaluation/best practices. NPA implementation is supported in part by OMH and several contracts managed by OMH to assist with coordinating, monitoring, and sustaining the NPA. Support includes assistance with: • ImplementationImplementationImplementationImplementation —coordinating and facilitating council meetings, consulting with leaders and experts, engaging communities, developing content for Blueprints for Action, producing tools and materials, working with partners to ensure connection and integration with implementation actions
  • 34. or plans, building partnerships, and providing implementation capacity building support. • CommunicationsCommunicationsCommunicationsCommunicatio ns—crafting and integrating NPA messages for various audiences, developing communication tools, and helping disseminate NPA information to key audiences in various formats as a means for sharing knowledge about activities, emerging issues, priorities, and evaluation/best practices. • EvaluationEvaluationEvaluationEvaluation—managing and monitoring evaluation activities to ensure that partners connect and contribute to the NPA evaluation; providing capacity building support to communities; and negotiating data use and reporting with agencies who manage data systems relevant to the NPA. Initial implementation will roll out in stages. Phase IPhase IPhase IPhase I involves the activities of the FIHET, FIHET subcommittees, and National Partners. Phase IIPhase IIPhase IIPhase II involves the activities of Regional Health Equity Councils, state offices of minority health, and expanded national partnerships with businesses and other communities. Phase IIIPhase IIIPhase IIIPhase III involves
  • 35. targeted multi-agency initiatives to minimize duplication and increase effectiveness. Current NPA implementation activities include the following: - Draft Background Paper 13 - 6 Phase1Phase1Phase1Phase1––––FIHETFIHETFIHETFIHET includes representation from 12 federal agencies as described above. The purpose of FIHET is to (1) identify opportunities for federal collaboration, partnership, coordination, and/or action on efforts that are relevant to the NPA; and (2) provide leadership and guidance for national, regional, state, and local efforts that address health equity. The FIHET played a critical role in providing feedback on the NPA’s development. Moving into the implementation phase, FIHET has established five subcommittees to develop implementation recommendations linked to the five NPA goals. Each subcommittee has developed work plans outlining its priorities,
  • 36. associated strategies that connect the work of federal agencies, action steps; as well as timelines and intended outcomes for each priority. Phase1Phase1Phase1Phase1––––National PartnersNational PartnersNational PartnersNational Partners work with the NPA to leverage resources, expand its reach and spheres of influence, infuse NPA goals and strategies into organizational policies and practices, and share stories and successes with their broad constituencies. National partners will include community- and faith- based organizations, professional societies, government agencies, national non-profit organizations, advocacy groups, foundations, corporations, businesses of all sizes, industry groups, and colleges and universities. For example, • The National Conference of State Legislatures (NCSL) The National Conference of State Legislatures (NCSL) The National Conference of State Legislatures (NCSL) The National Conference of State Legislatures (NCSL) is a bipartisan organization that serves the legislators and legislative staff of the nation's 50 states, its commonwealths and territories. NCSL works with OMH to help state legislators understand issues related to health disparities and how
  • 37. specific policies either narrow or widen disparities in health care for racial and ethnic minorities. • The Association of State and Territorial HeThe Association of State and Territorial HeThe Association of State and Territorial HeThe Association of State and Territorial Health Officials (ASTHO) alth Officials (ASTHO) alth Officials (ASTHO) alth Officials (ASTHO) recognizes that progress in improving the health of minority populations will require that states have access to information on effective practices as well as resources to assist in the implementation of effective public health policies and programs. ASTHO aims to fill these knowledge gaps, strengthen state leadership, and improve health disparities efforts through various activities under the NPA. • The National Association of State Offices of Minority Health (NASOMH)The National Association of State Offices of Minority Health (NASOMH)The National Association of State Offices of Minority Health (NASOMH)The National Association of State Offices of Minority Health (NASOMH) promotes and protects the health of communities of color, and tribal organizations and nations. Its NPA activities include technical assistance for SOMHs in engaging communities on NPA actions, building awareness, and incorporating or aligning state health disparity and/or health equity plans with NPA goals.
  • 38. - Draft Background Paper 13 - 7 • National Business Group on Health (NBGH)National Business Group on Health (NBGH)National Business Group on Health (NBGH)National Business Group on Health (NBGH) is a national, nonprofit devoted exclusively to finding innovative and forward-thinking business solutions to the nation’s most important healthcare challenges. As a NPA partner, NBGH is working to make the case to employers that addressing health disparities is a good financial and business decision. • The The The The National Rural Health AssociationNational Rural Health AssociationNational Rural Health AssociationNational Rural Health Association (NRHA) (NRHA) (NRHA) (NRHA) is a national nonprofit that provides leadership on rural health issues. Its role in the NPA is as a bridge connecting minority and rural health constituencies and needs, building awareness, and addressing actions for border populations. Phase IIPhase IIPhase IIPhase II————10 Regional Health
  • 39. Equity Councils10 Regional Health Equity Councils10 Regional Health Equity Councils10 Regional Health Equity Councils are being launched that will focus on groups of states nationwide. Initial planning meetings were held in four geographic regions prior to the launch of the NPA. The councils will address health disparity improvement actions for their geographic areas and work to leverage resources, infuse NPA goals and strategies into policies and practices, and share stories and successes with broad constituencies. The councils include individuals from the public, nonprofit, and private sectors and they represent communities experiencing health disparities; state and local government agencies; tribes and tribal organizations; healthcare providers and systems; health plans; businesses; academic and research institutions; foundations; and other organizations who focus on specific determinants of health (e.g., environmental justice, housing, transportation, education, etc.). Phase IIPhase IIPhase IIPhase II————State Offices of Minority Health (SOMH) State Offices of Minority Health (SOMH) State Offices of Minority Health (SOMH) State Offices of Minority Health (SOMH) are actively engaging communities through periodic meetings; developing strategic partnerships, mobilizing networks; improving awareness and
  • 40. communications through different media outlets; and leading states’ efforts in updating health disparity or health equity plans so that they align with the NPA. The SOMHs come together during monthly conference calls to update each other on progress, address challenges, share lessons learned, and consider collective actions. Evaluation The NPA Evaluation Plan provides a roadmap for determining the effectiveness of NPA strategies and actions. It describes the overall approach, key indicators and measures, data sources, and potential data collection methods. The goal of the evaluation is to ensure the integration and penetration of NPA efforts across sectors (e.g., education, housing, environmental health) and across levels (i.e., federal, national, regional, state, tribal, and community). A logic model was created by a team of expert advisors to illustrate the implementation pathway and anticipated outcomes of the NPA. The model is based on - Draft Background Paper 13 -
  • 41. 8 the assumption that observable changes in the way public and private organizations work across sectors to address the social determinants of health are more likely to occur initially than are observable population-level outcomes. Therefore, the initial focus for evaluation is to determine whether (1) organizational and structural changes have actually been made on behalf of health equity; (2) specific actions have been taken that align with the NPA’s five goals and 20 strategies; (3) public awareness and understanding about social determinants has increased; (4) policy, systems, and other multi-level changes have been initiated; (5) there is an increase in communities’ capacities to address health disparities through the use of data for decisionmaking; and (6) whether promising practices can be identified. Evaluations will also consider the feasibility of developing and using a social determinants health equity index to assess how well the nation is progressing towards improved health outcomes.
  • 42. Even with an optimal social determinants index, it will take several years before observable changes can be expected. The evaluation plan has identified initial optimal indicators and measures. Some of these measures are already available; others will need to be developed. To the degree possible, evaluation teams will coordinate NPA evaluations with those of other federal entities and with NPA partners in order to minimize duplication and to build on existing data analyses and sources. Evaluation teams will work with OMH leadership to facilitate the development of data-sharing agreements and protocols. Current proposed indicators are as follows:
  • 43. - Draft Background Paper 13 - 9 Exhibit 2: Current Proposed Evaluation IndicatorsExhibit 2: Current Proposed Evaluation IndicatorsExhibit 2: Current Proposed Evaluation IndicatorsExhibit 2: Current Proposed Evaluation Indicators Infrastructure and Partnerships Productive and effective health equity councils, including the Federal Interagency Health Equity Team and the national, regional, state, tribal and community health equity councils Productive and effective NPA Partnerships (e.g., Association of State and Territorial Health Officials, National Conference of State Legislatures, National Business Group on Health, National Association of State Offices of Minority Health) Vertical (e.g., between state and region) and horizontal (e.g., among states or regions) alignment among national, regional, state, tribal, and local efforts Actions Multi-sector and multi-level actions Goal attainment
  • 44. Alignment between actions and results Capacity for implementing strategies to end health disparities Public Awareness and Understanding Awareness of NPA Awareness of health disparities and understanding of social determinants News coverage from print, broadcast, and internet news sources on health-related issues affecting underserved and racial and ethnic communities (including mainstream and selected racial and ethnic print news sources) Policy, Systems, and Other MultiPolicy, Systems, and Other MultiPolicy, Systems, and Other MultiPolicy, Systems, and Other Multi----level Changelevel Changelevel Changelevel Changessss Influence of NPA on its partners Inclusion of health disparities or health equity concepts and language (e.g., social determinants) in mainstream institutions and among broad leadership Influence of NPA on local, state, and national healthcare-related policies Influence of NPA on local, state, and national policies, procedures, and practices that address the social determinants of health
  • 45. - Draft Background Paper 13 - 10 Evaluators will select a final list of indicators and measures, as well as the sample of regions, states, and organizations that will be included in the initial evaluation. In general, data collection activities can be summarized into the following types: • Surveys of the FIHET, Regional Health Equity Councils, and NPA partners; • Review and analysis of the goals and strategies implemented by the FIHET, Regional Health Equity Councils, and NPA partners; • Content analysis of NPA partners’ programs, agendas, materials, plans, etc.; • Interviews with key informants at the federal and national levels and in the regions, states, and tribes that are part of the sample.
  • 46. Cross-case study method will be used to analyze the data. This method allows for comparisons across and within selected regions, states, and communities, as well as the combined use of qualitative and quantitative methods. The findings will be compiled into case studies. Each case study will tell the story of what transpired in each of the sample geographic units and will provide insight into the context and circumstances under which changes did or did not take place. Each case study will, in turn, contribute to a national, in-depth case study on the NPA’s effectiveness. Time-series presentations of data will also be conducted in order to show changes. The evaluation team will submit semiannual reports on its progress, and annual reports that will contribute to the OMH reports to the U.S. Congress. Annual reports will also be provided to the FIHET, Regional Health Equity Councils, NPA partners, and the implementation and communications teams. Reports will be posted on the NPA website and made available and accessible to the public. The evaluation team will facilitate a meeting to reflect and discuss the findings with OMH leadership and
  • 47. staff, the implementation teams, and the communications teams. Meetings will focus on the lessons learned and the implications for iterative strategy improvement and implementation. Follow-up and lessons learned Efforts to end health disparities are inherently a comprehensive community and systems change effort. The NPA is about change: why there should be change, who should effect the change, and the strategies - Draft Background Paper 13 - 11 that can be applied to implement change. The changes needed can take place only with the cooperative effort of individuals at all levels of public and private enterprise. Managing and coordinating the magnitude of planning and implementation activities has been one of the greatest challenges of the NPA. That challenge continues as the NPA deliberately plans for further growth with phased and monitored expansion of the number of
  • 48. NPA partners and activities. Past experiences in driving a health equity agenda underscore the lesson that comprehensive efforts take time, significant resources, and the efforts of many partners. Beyond financial and human capital, these efforts also require significant coordination, transparency, and commitment. The growth of the U.S. knowledge base, constituency, and programs for health equity in the past few decades has formed the foundation necessary to initiate and sustain the NPA. Individuals across sectors have committed to participate in NPA activities because of their passion and commitment to its vision and goals. The NPA represents a grassroots effort to form strategic partnerships and engage communities and organizations on behalf of health equity. As a grassroots effort, all partners have had to “own” the NPA in order for it to survive and thrive. Continued progress is dependent on success in transforming the quality and commitment of stakeholder partnerships. Ideally, individuals and organizations will expand their sharing of resources and spheres of cooperation beyond customary relationships to include partners that can enhance mission capacity and value in new and
  • 49. effective ways. The holistic approach of the NPA to integrate implementation, communication and evaluation activities supports participants as they unite to prioritize common goals, share successful strategies, and move from planning to action. The objective is to advance implementation, communication and evaluation at a pace that maintains their coordination and alignment while also maintaining the engagement of all stakeholders. The NPA is forging a new path for which there is no prior roadmap. Lessons are learned as actions are planned and executed. Partners and experts are continually encouraged to address new and emerging opportunities. An important lesson has been that an understanding of the social determinants of health does not in itself bring expertise for creating change or forming new relationships and partnerships. Thus, capacity-building opportunities and tools (e.g., educational webinars, targeted messages, and access to experts for consultation, etc.) to facilitate effective participation are being developed. Although early in its implementation, the NPA has already made a difference in the way partners frame their work, individually and collectively. There is evidence that
  • 50. FIHET member agencies are beginning to - Draft Background Paper 13 - 12 use the NPA goals to develop priorities and scope of activities, which translates into positive opportunities for communities. In addition, FIHET members have consistently engaged and recruited others to join the NPA. Elsewhere there has been an emerging pattern among organizations to work collaboratively and strategically toward common goals. NPA partners are increasing their knowledge about disparities, public/private sector infrastructure and resources for addressing disparities, and how health equity efforts can and should be integrated into the broader national dialogue. A key lesson learned is that the NPA achieves a momentum for change as it creates a national forum and strategy for cooperation.
  • 51. - Draft Background Paper 13 - www.who.int/social_determinants/www.who.int/social_determin ants/www.who.int/social_determinants/www.who.int/social_det erminants/