Ensuring that money intended for health equity is well spent

The COVID-19 pandemic has prompted unprecedented federal relief and recovery funding for states and localities, which comes with an equally unprecedented level of flexibility in how the money can be spent. Such flexibility must come with accountability.

While financial freedom can help communities deploy funds in ways that address their unique needs, the Biden administration must actively measure and evaluate the spending to ensure money is being used to advance equity. Indeed, the Biden administration has consistently identified racial equity as a north star for pandemic recovery efforts and the Presidential COVID-19 Health Equity Task Force has recently released a set of recommendations in this regard. But states and localities need immediate guidance for how they should make decisions about their spending. Equity must be built into the decision-making process and allocation of resources, not just measured at the end of an investment. 

Cities, counties and states can use funds from the CARES Act, American Rescue Plan Act, American Jobs Plan and other funding sources to tackle systemic inequities exposed during the COVID-19 pandemic — but how will we know that this is being done, done well, and baked into their initial decision making?

A successful framework to measure equity can help state and local jurisdictions employ funds as intended — and hold city, county and state leaders accountable for focusing on equity in their decision-making and programmatic choices.

Last month, a group of policy officials, experts and thought leaders came together to discuss principles and guideposts for an equity-centered decision-making process, reporting requirements, and needed policy changes and support systems, convened by the George Washington University Milken Institute School of Public Health and Georgia Health Policy Center.

What emerged is a framework that policymakers can apply across federal, state and local investments going forward to demonstrate adoption of a process — and plan for outcomes — that reflects the importance of addressing equity. The key principles reflect the importance of bringing the community to the table and ensuring such inclusion is real; ensuring that traditional power structures are not reinforced in funding; and collaborating across agencies and with the community. 

Because local and state governments have different capacities to engage in multi-sector and multi-racial collaborative decision-making, support is needed from the federal government, community-based organizations, or both. This could include real-time clearinghouse of activities and practices from across the country or training in communication, racial healing and relationship building. 

Inspiration from similar frameworks can be adapted. The Funders Forum for Accountable Health created a health equity assessment framework for cross-sector, community-based partnerships known as Accountable Communities for Health. The framework includes a common definition of health equity, specific domains to measure progress, and guiding questions. 

In Harris County, Texas, the local government developed and implemented an Equity Framework to guide how nearly $1 billion in American Rescue Plan funds could equitably address priority areas of health, employment and housing. Strategies will guide Harris County in selecting, developing, implementing and evaluating programs that advance equity.

Cities nationwide are building equity frameworks and structures into their planning and implementation efforts of American Rescue Plan funds. Those participating in National League of Cities’ Cities of Opportunities, for instance, are using these flexible funds to invest in capacity building to advance equity. This includes developing plans, structures and roles for accountability to undergird equity work for the long term and engaging residents and cross-sector leaders in the co-creation process.

To create a more equitable future, the Administration needs to establish a framework to evaluate how states and cities are advancing equity — and can find inspiration from existing examples. Once a framework is established, it could serve as an equity measurement across other federal programs.

Jeffrey Levi, Ph.D., is a professor of health policy and management at the George Washington University’s Milken Institute School of Public Health. Levi is principal investigator on the Aligning in Crisis project (a partnership between the Georgia Health Policy Center and Milken Institute School of Public Health with support from the Robert Wood Johnson Foundation) working to implement policies that facilitate recovery from the triple crisis of the COVID-19 pandemic, the resulting economic struggles and the ongoing impact of systemic racism.