Building More Equitable Project Structures: Recommendations for State Public Health Agencies


To ensure public health initiatives have long-term impact and break down barriers causing health inequities, public health practitioners understand that creating sustainable systems change is necessary. This approach addresses the root causes of systems, with individuals and organizations analyzing structures such as policies, practices, power dynamics, partnerships and social norms that are currently in place.

Recognizing that implementing changes to the structures in place can be challenging, the Strategies to Repair Equity and Transform Community Health (STRETCH) Initiative aimed to help states practically apply a systems change approach to specific projects, while showcasing how the approach can be applied across projects.

The STRETCH initiative—a partnership between the Association of State and Territorial State Officials (ASTHO), Michigan Public Health Institute (MPHI) and the CDC Foundation—brought 10 state public health agencies (SPHAs) together to establish a peer learning network to strengthen their cross-sector and cross-agency relationships to build strategies for lasting systems change.

Strategic Prevention Solutions, with support from the project partners, led the evaluation of the STRETCH Initiative’s approach and effectiveness by analyzing participant feedback from surveys and interviews, project scopes and individual project progress. Below are takeaways from the STRETCH initiative for other state health agencies to consider when strengthening their approaches to health equity work.

Flip the Approach

Often in organizations, there are established policies, procedures and roadmaps to how projects develop and, typically, projects start with specific goals aligned to priorities. STRETCH flipped the approach by initially asking participants to focus outside of individual projects and first assess the foundational aspects of systems change: relationships, power dynamics and policies and procedures.

Teams reflected on their current conditions by asking questions such as: What processes and policies are in place? What established relationships do we have? What assumptions or deeply held beliefs are influencing the way we think, how we talk and what we do to address public health issues?

Looking to foundational aspects of the work highlights the root causes of why certain challenges persist in public health and builds upon the STRETCH framework, a roadmap for creating sustainable, long-term change to reduce health disparities by taking a systems change approach to public health.

Focus on Small Steps and Actionable Items

True systems change—meaning we have continually altered the structures and not for only one time—requires a myriad of steps to get to the final change movement. When measuring progress, do not forget the smaller steps that are often overlooked in everyday public health work. Establishing leadership buy-in and building cross-departmental relationships are milestones that lead to sustainable projects and bridge building for long-term success.

Peer Learning Community Builds Sustainability

An emphasis on peer communication internally across departments as well as externally with partners and other state agencies builds a network of collaborators. STRETCH virtual workshops guided states to analyze processes and procedures, build consistent relationships and establish narratives. These group sessions provided the 10-state teams with opportunities for different types of technical assistance and cross-collaboration and encouraged a problem-solving approach that the teams could apply to their state-specific contexts.

Jerome Staab, from the Kansas Department of Health and Environment team, explains “With the open environment, you get great dialogue. It breaks down some of the…barriers and the silos…you’re also able to just troubleshoot the problems.”

Building actionable processes and initiatives to create change in our communities takes time. By intentionally making incremental changes to our approaches, we move towards more sustainable health equity practices that give everyone the opportunity to live their healthiest life.


The Strategies to Repair Equity and Transform Community Health (STRETCH) Initiative is a partnership between the CDC Foundation, Association of State and Territorial Health Officials (ASTHO) and Michigan Public Health Institute (MPHI) with support from Robert Wood Johnson Foundation. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, the Robert Wood Johnson Foundation. STRETCH 2.0 is currently accepting applications, learn more about this opportunity through the STRETCH webpage.

Francesca Hill
Francesca Hill is a senior communications officer at the CDC Foundation.