PPH links communities, public health departments and other entities to implement the bold changes in policy and practice needed to eliminate health inequities and build vibrant, healthy communities.

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A Vision to Transform Health and Social Equity in California and the U.S.

As a pioneer in creating healthy communities for more than a decade, Partnership for the Public's Health (PPH) now sees the opportunity to build a powerful multi-level network catalyzing momentum to reverse the tide of chronic disease. Partnering with local collaboratives to promote strong and sustainable leadership within California's low income communities, the PPH model links these communities through a robust statewide network. Together, this networked community will help generate the sustained "tipping capacity" required to address social determinants of health, and promote health, social and economic equity in California and elsewhere in the U.S.

The Joint Challenge of Health and Social Equity

Despite hundreds of billions of dollars spent on prevention and treatment, over the past fifty years the number of people in the U.S. affected by chronic disease has soared to unprecedented levels, and low income communities and people of color continue to be the most severely affected. The surge of chronic disease has far-reaching impact on the U.S. health care system, our society and our economy.

Clear and convincing evidence has emerged that racial and socioeconomic inequities are the drivers of this epidemic.^1,2 In response, many social change activists have mobilized to address root inequities through resident capacity-building, community organizing, policy and systems change. Yet, the full impact of these efforts remains greatly inhibited by two key obstacles:

• Fragmentation of society. At present, U.S. society seems intractably fractured along lines of class, race, education, political ideology and religious affiliation. In the absence of greater social cohesion and sense of common purpose — that is, social capital — both environmental and systems improvements are fragile and subject to constant flux driven by competing interest groups.
• Fragmentation of effort. Stakeholders and campaigns addressing the social and economic drivers of health inequity are diverse and multi-level. No current vehicle fully connects, leverages and focuses stakeholders and campaigns toward major social transformation locally, statewide and nationally.

PPH Theory of Change

The PPH Theory of Change draws on lessons from community-based public health, grassroots activism and social enterprise innovation. In it, a movement that produces transformational change in health and social equity must develop and integrate all three of the following essential components:

1. Expanding Social Networks: In 2000, Robert Putnam changed the paradigm for social action with his revolutionary analysis of the breakdown of social capital in America.³ Putnam and other analysts, including Richard Wilkinson and Kate Pickett,¹ stress the crucial role that trust, social status and community bonds play in health. Yet despite its critical importance to health, social well-being and political consensus, social capital has not yet been intentionally and rigorously incorporated, measured or brought to scale in movements that promote health and social and economic equity.
   
   We focus on building resilient social networks at the local, state and national level, across lines of class, race, education, age, profession, religion and political affiliation, as the critical path to achieve deep and lasting social transformation.
   
   Example: The PPH Initiative and the HEAC program brought to the collaborative table as equals, community residents, with local health departments, CBOs, school districts, and others. PPH, HEAC and California Convergence have linked local leaders across communities.
2. Coordinated Social Action: Strong social networks and relationships alone do not solve all social problems; but they lay the essential groundwork to make problems solvable through coordinated action. These actions build on each other, continually increasing the skills, knowledge base and influence of low income and other stakeholders, and result in tangible improvements in low income communities.
   
   PPH-supported networks unite low income residents and youth and a wide range of diverse interest groups, offering a platform for powerful and focused action, and create opportunities for regional, state, and national action.
   
   Example: HEAC collaboratives have improved access to healthy foods and places to be physically active, reclaiming parks, creating farm stands, and changing city general plans.
3. Equitable Policies and Social Systems: Policy and systems change play a critical role in promoting social equity. They are not, however, ends in themselves. Without a solid constituency that ensures their appropriateness and assures their implementation, policies can be ineffective. Systemic changes are only valuable to the extent that they promote an expanding "virtuous cycle" of social cohesion, increased economic opportunity and improved well-being for Americans.
   
   PPH networks provide a structure that translates new policies into expanded, increasingly resilient social networks that carry social action forward to a new level.
   
   Example: California Convergence communities identified safety/violence issues as a core impediment to being physically active which, unaddressed, would make other policy changes ineffectual. Youth leaders on this and other issues are meeting to craft a statewide policy platform.

Results: A Dynamic, Expanding Virtuous Cycle of Health and Social Equity

PPH 2010 - 2015: Strategies and Outcomes

PPH and partners will implement the Theory of Change using five strategies:

1. Network Development: Develop intentional, action-oriented social networks that connect diverse stakeholders and decision-makers to advance health equity, at two levels:
   • Community-based networks: Local collaboratives build social capital by leveraging the capacity of low income residents and youth as problem-solvers and agents of change, connecting diverse local stakeholders, and providing a platform for action in common.
   • Statewide "network of networks": A robust statewide network of local collaboratives creates a learning community, expands local leaders' sphere of influence, and develops collective state and national agendas.
2. Capacity-Building and Leadership Development: Continually build the leadership of low income residents, youth and other stakeholders to take coordinated, relevant, intentional action over time. Build an innovative institutional capacity at the local and state level that models and expands social equity.
3. Targeted Resource Development and Financial Innovation: Drawing from best practices of the social enterprise movement, develop financial resources at the local and state level that institutionalize, sustain and expand the impact of the movement.
4. Policy and Systems Change: Promote policies and systems that improve social determinants of health, increase equitable access to essential resources, expand social cohesion, and support new opportunities for community action and improvement.
5. Evaluate and Publicize Results: Make issues, methods and results visible both inside and outside the movement in order to influence and engage ever broader and more diverse stakeholders in health and social transformation.

PPH: In the Vanguard Transforming Health and Social Equity

PPH leverages a decade of experience and expertise advancing health and social equity through collaboration, social action and systems change.

• Sponsored by The California Endowment (TCE), in its original initiative PPH developed, implemented and evaluated a ground-breaking social capital-based methodology, making and managing grants to 39 community collaboratives across California. Through these collaboratives, low income residents worked in partnership with local health departments to address social determinants of health at the local level.
• Drawing on best practices from the original PPH initiative, TCE again sponsored PPH to apply a similar methodology to address social determinants of obesity and diabetes. Working deeply with six California-based community collaboratives, PPH provided grants management, technical assistance, leadership/capacity building and peer learning networks to maximize the impact of grantee activities to improve food and physical activity environments in their communities.
• In 2008, TCE and Kaiser Permanente Community Benefit Program jointly funded PPH to develop and manage the California Convergence, providing an exemplary regional model for the National Convergence Partnership. California Convergence links California-based communities engaged in improving food and physical activity environments to prevent obesity and chronic disease. A 2010 evaluation of the model showed evidence that a "network of networks" has strong potential to lift up community leaders, who could take coordinated action with greater impact at the state and national level.

1. In The Spirit Level: Why More Equal Societies Almost Always Do Better (2009), British demographic researchers Richard Wilkinson and Kate Pickett assert that income inequality is a major cause of growing health and social problems in the U.S.
2. In 2008, the documentary series Unnatural Causes explored the role that racial and socioeconomic inequities play in degrading health in low income communities.
3. Bowling Alone: The Collapse and Revival of American Community, Robert Putnam, 2000.

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