The past decade has seen increased emphasis on the importance of advancing health equity and addressing the social, political, and economic drivers of health inequities. Achieving health equity requires moving beyond health care to address the social and economic conditions and the political determinants of these conditions that drive health within communities [1]. Key to advancing equity is embracing an anchor mission strategy and forming partnerships between “anchor institutions” and local organizations to invest in the economic well-being of communities [2]. Anchor institutions are nonprofit or public entities such as hospitals and universities that have the ability to align and deploy their institutional resources—such as hiring, purchasing, and investing—with the needs of the local communities they serve [3].
Place-based investing is an impactful yet underutilized strategy that can be leveraged by anchor institutions to improve community health and advance health equity [2]. Place-based investing allows institutions to experience social and financial returns by focusing investments on community-level factors that promote health and well-being. Investments in social determinants (drivers) of health—“the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life” [4]—enhance the health of communities while earning the institution a healthy rate of return. Healthy People 2020 outlined five areas of social determinants of health: economic stability; education; social and community context; health and health care; and neighborhood and built environment [5]. Health system investment in social drivers of health—particularly housing—has increased significantly in the past several years [6], and Healthy NC 2030 takes this work forward in our state.
Widespread racial/ethnic and socioeconomic disparities in North Carolina warrant a focus on addressing social drivers of health [7]. Based on 2019 data, 1.4 million North Carolinians, or about 1 in every 7 people in the state, live in poverty [8]. Data from 2020 showed that nearly 1 in 3 adults in North Carolina had difficulty paying for household expenses, with Hispanic/Latino and Black people having much higher rates of difficulty than White people [9]. Overall, the rate of food insecurity—i.e., not having access to enough food for an active, healthy life—in North Carolina pre-COVID was 13.5%, with rates as high as 19% in one county [10].
North Carolina health systems are well positioned to address these disparities [11]. UNC Health, as the state’s safety net hospital, has a mandate and mission to improve the health and well-being of North Carolinians that cannot be accomplished without a firm commitment to addressing social and economic drivers of poor health within communities. Health systems including UNC Health, Vidant Health, and Cone Health have access to resources and an accountability structure through their membership in the Healthcare Anchor Network, a collaborative network of over 65 health systems that are committed to adopting the role of anchor institutions in their communities [12]. North Carolina also has an abundance of community partners with whom to advance community health and well-being. Notably, North Carolina is among the states with the most community development credit unions (e.g., Latino Community Credit Union, Self-Help Credit Union), which are specifically designed to deliver financial services and capital to low-income individuals and communities. Finally, North Carolina has demonstrated its ability to be innovative through the Healthy Opportunities initiative, through which the North Carolina Department of Health and Human Services and Blue Cross Blue Shield are transforming how health care is delivered and social drivers are addressed for Medicaid beneficiaries in the Eastern and Western regions of the state [13].
Health systems, particularly UNC Health with its broad and growing footprint across the state, have a unique opportunity to mitigate socioeconomic disparities, redistribute wealth, and extend opportunities for individuals to achieve their fullest health potential by investing time, talent, and treasure wisely. We offer several specific strategies for doing so.
Hire Locally
Considering the current strains on the health care workforce, health systems can build their staff while supporting employment opportunities and job training for low-income, rural, and historically marginalized individuals. These efforts should eliminate barriers to employment by providing local applications and interview opportunities in communities and removing the requirement to divulge information about criminal history during the initial stages of employment. Health systems such as Cone Health and Vidant Health have both implemented “Ban the Box,” an executive order signed by Governor Roy Cooper on August 18, 2020 [14], that removes the box on an application that asks about criminal history. Additionally, health systems should develop or strengthen workforce development programs to ensure entry-level workers have access to training, internships, career counseling, and job advancement opportunities. Health system leadership should consider setting clear goals related to hiring more staff from socially vulnerable communities, using existing tools such as the Centers for Disease Control and Prevention’s Social Vulnerability Index (SVI) [15].
Purchase Locally
North Carolina health systems should prioritize sourcing from diverse local suppliers. US health systems spend less than 2% of an estimated $340 billion annually on goods and services from minority- and women-owned business enterprises (MWBE) [3]. Health systems should strongly encourage (or require) their large suppliers to subcontract with local vendors. Moreover, to ensure equity of opportunity, health systems could consider requiring at least one MWBE to participate in the bidding process of any contract over a certain dollar value. North Carolina health systems can learn from successful models such as Cleveland’s Greater University Circle Initiative, a collaboration between a university, a health system, and a civic organization that generated funds and pooled resources to buy and hire locally, resulting in a procurement of $3.6 billion in goods and services in a single year, increasing purchases from local vendors [3].
Volunteer Locally
Health systems are rich in human resources and talent, particularly related to budget/finance, strategic planning and operations, human resources, communications and marketing, and philanthropy. Encouraging and allowing paid time off for team members to share their skills and expertise with local community organizations is a “win-win.” The health system is able to advance its mission; team members get joy and fulfilment from contributing to the greater good; and local organizations, many of which are resource constrained, receive support and skills-building in key areas necessary for enhancing business. Moreover, to emphasize the importance of community involvement, systems can include volunteerism across all levels of team members as an organizational goal that gets tracked and incentivized.
Invest Locally
Health systems should aim to allocate at least 1% of their investment portfolio, or $50 million, whichever is less, to targeted place-based community investments [16]. These investments should address social drivers of health with a particular focus on communities that have a legacy of disinvestment and discrimination. Health care systems across the nation have found success investing through an impact investment fund or through financial intermediaries such as community development financial institutions and banks, partnering with nonprofits or local businesses and developers, or investing directly in specific projects [3]. To maximize community benefit from these types of initiatives, it is important for health systems to involve their team members in identifying investment priorities.
The success of North Carolina’s health systems is inextricably linked to the local communities they serve. Adopting an anchor mission allows health systems to leverage the full power of their organizations to develop and implement strategies to address systemic issues tied to poverty and structural inequities. The success of the anchor strategies described here requires buy-in and commitment from governing boards and leaders at the highest levels of each organization, willingness to listen and engage in multisectoral partnerships, and the development and monitoring of accountability metrics. The question is not whether North Carolina health systems can accomplish the goal of being an anchor in their communities; it is when they will fully commit to doing so, and how they will sustain their commitment when it feels safer to focus on providing health care instead of promoting health and well-being.
Acknowledgments
Disclosure of interests. The authors reported no interests to disclose.
- © 2022 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.
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