Building Systems Change for Equitable Public Health Systems

Public health faces challenges to achieving health equity throughout our communities. These challenges range from the long-term effects of a legacy of disinvestment in public health to a workforce deeply impacted by the COVID-19 pandemic to structural biases and issues in addressing the social determinants of health.

Within each of our communities, we must build the pathway for everyone to have access and the opportunity to thrive and live their healthiest lives.

To ensure our efforts have long-term impact and break down barriers causing health inequities, public health practitioners understand creating sustainable systems change is necessary. These practitioners also understand this approach requires adjusting and transforming the policies, practices, power dynamics and the social norms that have allowed health inequities to persist, despite laudable efforts of the field.

The events of the past two years, including the disproportionate harm experienced by communities of color and other marginalized populations and the increased awareness of racialized violence, have, rightfully, focused attention on the root causes of health inequities, including structural racism, systematic biases and other forms of oppression.

So, how does public health prioritize our work to take action?

The Strategies to Repair Equity and Transform Community Health (STRETCH) Initiative has synthesized different perspectives into an action-oriented framework that emphasizes addressing root causes to achieve health equity.

The STRETCH Initiative focuses on bringing together public health agencies and their community partners for a common goal: designing meaningful, lasting systems change to create inclusive, equitable public health systems.

The initiative urges state health agencies, in collaboration with their community partners, to leverage the influx of new funding to drive impact and embed equity into priorities, programs and all levels of their organizations.

By addressing root causes through a systems change approach, the STRETCH Framework guides action and reimagines current public health models to lead to more equitable outcomes.

The STRETCH Framework includes five domains to guide systems change processes, providing ways of assessing an organization’s readiness to undertake the promotion of policies, programs, protocols and mindset shifts needed to achieve health equity:

  1. Community-led approaches: Centers health equity actions on the community priorities regarding what is needed to improve their health and wellbeing.
  2. Place-based initiatives: Develops collaborative, long-term approaches to build thriving communities defined by place, interest or action.
  3. Workforce development: Ensures the quality and capacity of the workforce meets the current and future public health challenges and improves health and equity outcomes for the communities served.
  4. Data-driven mechanism: Reimagines how data is collected, shared and used to illuminate the needed investments to improve health equity.
  5. Finance systems: Focuses on how agencies can organize their finances for long-term sustainability and success.

By exploring all of these areas as an integrated web instead of siloed operating functions, public health agencies can work towards fruitful partnerships with communities and intermediaries that can stretch the impact of projects and lead to long-term change.

These partnerships can offer new perspectives and help ensure all voices are invited to the table and contribute to the outcome. A range of partnerships is key to ensuring the funding coming to state public health agencies, which has increased considerably during the COVID-19 pandemic, is invested across communities and is utilized to create long-term, sustainable change.

Notably, the STRETCH Framework is designed to support power-sharing in community partnerships while building ongoing trust.

By addressing root causes of health inequities within our communities, we can build meaningful, lasting systems change to create inclusive, equitable public health systems and, ultimately, improve health equity.

The STRETCH Initiative is made possible in partnership with Association of State and Territorial Health Officials (ASTHO) and Michigan Public Health Institute (MPHI) and through support from the 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. 

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