Achieving health equity requires a multidimensional and integrated public health infrastructure. Structural components must encompass a wide range of elements including cultural knowledge, research, policy making, partnerships, evaluation, and workforce development. According to Healthy People 2020, a strong infrastructure provides the foundation for planning, delivering, and evaluating public health initiatives and is composed of 3 areas: “a capable and qualified workforce, up-to-date data and information systems, and public health organizations capable of assessing and responding to public health needs.”1 Much has been published on definitions for health equity and the types of research, programs, and policies needed to reduce health disparities.2–62–62–62–62–6 Meanwhile, the literature on necessary structures and functions needed to address health equity within public health organizations remains in an early stage of development and has focused primarily on social determinants of health.7,8
As a means of illustrating elements necessary for a robust health equity infrastructure, we examine the Centers for Disease Control and Prevention (CDC), the chief federal agency charged with protecting the public health of the nation. We do so because the agency has extensive experience to draw from providing leadership and direction in the prevention and control of diseases and other conditions that affect public health.9 CDC has an extensive history of working to promote health equity through the implementation of public health science, programs, policies, and partnerships to enhance awareness and prevention of the leading causes of illness, injury, disability, and death for all Americans.10
CDC's organizational structure to promote health equity is composed of centers, a national institute, and several offices, collectively referred to as CIOs. Each CIO implements public health programs and responses in its area of expertise, with a focus on reducing health disparities and promoting health equity while also providing intra-agency support for crosscutting issues and specific health threats.11 CDC's CIO organizational structures and functions are supplemented by agency-wide employee-led health equity workgroups and other health equity–related entities.
This article discusses elements of CDC's organizational infrastructure that support and promote health equity. We include examples from CIOs to identify those structures and functions that are critical to achieving health equity and note several challenges to sustaining a health equity organizational infrastructure. Finally, we provide additional considerations for expanding and sustaining a health equity infrastructure, which the authors hope will serve as “food for thought” for practitioners in state, tribal, or local health departments, community-based organizations, or nongovernmental organizations striving to create or maintain an impactful infrastructure to achieve health equity.
A 4-step process was conducted in 2014 to gather and summarize information on organizational structures and functions within CDC devoted to promoting health equity. First, a literature search was conducted to gather information on organizational structures for health equity both to understand the various organizational models in the published literature and to understand the origins of health equity organizational structures at CDC. Second, internal CDC documents and Web sites were reviewed to characterize the types of organizational structures and functions in place designed to promote health equity. Third, additional information was gathered through a series of meetings with health equity experts and leaders within the agency. Finally, on the basis of information gathered in steps 2 and 3, a purposive sample of experts and leaders from CDC CIOs was selected to gather additional information for this article.
Our review found that many and diverse elements of health equity infrastructure are in place across CDC. The following background is intended to offer the reader a sense of the historical development and function of this infrastructure and to explore the diverse organizational structures that different components of the agency employ.
CDC-wide organizational structures to support health equity
In this section, we discuss the origins and current status of CDC's agency-wide offices devoted to the promotion of health equity in the areas of minority health and women's health, noting how these structures emerged in the context of societal developments.
CDC's Office of the Associate Director for Minority Health
Current federal organizational structures for addressing health disparities have deep roots that have unfolded throughout the history of the United States. In 1985, then-US Department of Health and Human Services (HHS) Secretary Margaret Heckler released the Report of the Secretary's Task Force on Black & Minority Health.12 This landmark report documented excess deaths from 6 diseases in racial and ethnic minority populations and made 8 primary recommendations to improve individual and community health that continue to be relevant today. The report influenced HHS to establish its Office of Minority Health in 1986 and CDC to establish its Office of the Associate Director for Minority Health in 1988. More recently, the Affordable Care Act (ACA) of 2010 built on this action and authorized offices of minority health in each HHS agency, requiring the offices to report to the agency director or administrator.13
CDC's Office of Women's Health
National efforts such as the 1993 Women's Health Equity Act and related congressional appropriation language encouraged the establishment of the CDC's Office of Women's Health in 1994 (CDC, unpublished data, 1997). Government reports that helped lay the foundation for the creation of HHS offices of women's health include the landmark 1985 Women's Health. Report of the Public Health Service Task Force on Women's Health Issues14 and the 1991 PHS Action Plan for Women's Health.15 Calls by activists, organizations, individuals, and congressional leadership urged the health care, biomedical research, and academic communities to make women's health a priority.16,17 At the same time, efforts expanded the definition of women's health beyond reproductive issues to encompass diseases and conditions that are unique to women, are more prevalent or serious in women than in men, and/or have different risk factors or interventions for women compared with men.14
The CDC's Office of Women's Health was established in 1994 to ensure that women's health issues were addressed in CDC's prevention efforts. Women's health was designated as 1 of 4 emerging CDC priorities and an associate director for women's health was appointed, reporting directly to the CDC Director (CDC, unpublished data, 1997). HHS offices of women's health existed in numerous agencies, but several were only authorized through the passage of the ACA in 2010.13
CDC's Office of Minority Health and Health Equity
Today, CDC's Office of Minority Health and Health Equity (OMHHE) is located in the Office of the Director at CDC, and the OMHHE Director reports to the CDC Director. In 2013, CDC's leadership expanded OMHHE to include the Office of Women's Health, along with the Diversity and Inclusion Management unit. A separate Minority Health and Health Equity Unit was also created.
OMHHE accelerates the work of CDC and its partners in improving public health by eliminating health disparities, promoting conditions conducive to health, and working toward achieving health equity. In addition, it provides leadership and support for the agency's research, policy, and prevention initiatives to promote and improve the health of women and girls and helps ensure implementation of CDC's diversity policies, procedures, and practices.18 OMHHE works to reduce health disparities and achieve health equity by focusing on social determinants of health, health disparities research (including analysis by race, ethnicity, sex and gender, and other important health equity domains), and supporting pipeline programs to ensure a diverse public health and health care workforce prepared to reduce health disparities.
Working to achieve health equity in CDC's CIOs
With the establishment of these entities in CDC's Office of the Director, there have been efforts to parallel the structure and functions throughout the agency. These health equity organizational structures and functions have taken 2 basic forms: a centralized structure in the leadership unit (Office of the Director) of the particular center, institute, or office; or a diffuse organizational structure with leadership throughout the center in divisions or teams.
In the centralized structure, a designated leadership role with an appointed senior staff person (the associate director for health equity) is located within the leadership unit of the CIO, typically the Office of the Director. An office with dedicated staff may also function to carry out health equity–specific work. The diffuse type of structure may take many forms. It is a decentralized approach where activities related to heath equity, minority health, and women's health are led by staff with a range of roles and titles and may take place within branches and divisions without center-level leadership. We provide examples of the 2 structures to illustrate how they are operationalized in practice.
An example of centralized structure
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention's Office of Health Equity
The National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) works to save lives, protect people, and reduce health disparities by preventing HIV infection, viral hepatitis, sexually transmitted diseases, and tuberculosis. The infectious diseases NCHHSTP focuses on similar or overlapping at-risk populations—including racial and ethnic minorities, men who have sex with men, and injection drug users. These diseases also share similar social determinants of infectious diseases, including poor access to health care, stigma, discrimination, incarceration, homelessness, and poverty.
The NCHHSTP Office of Health Equity (OHE) was established as an official organizational unit within NCHHSTP's Office of the Director in June 2003. The mission of OHE is to improve the health of populations disproportionately affected by HIV infection, viral hepatitis, sexually transmitted diseases, tuberculosis, and other related diseases or conditions and ultimately to reduce health disparities. These populations include racial and ethnic minorities, women, and sexual minorities (eg, gay and bisexual men and women and transgender persons).
In addition to OHE in the NCHHSTP Office of the Director, health equity offices and/or coordinators have been established within all 5 divisions of the center: the Division of HIV/AIDS Prevention, the Division of Viral Hepatitis, the Division of STD Prevention, the Division of Tuberculosis Elimination, and the Division of Adolescent and School Health. These offices and coordinators provide a focal point for coordination, tracking, reporting, and promotion of health equity activities. A center-wide health equity workgroup and technical workgroups focused on populations or settings (eg, men who have sex with men, people who use drugs, young people, and correctional institutions) were established to promote collaboration, synergy, and sharing of best and promising approaches in addressing health disparities and promoting health equity. The work of OHE, division offices, and work groups are guided by Center and Division Strategic Plans, all of which formally recognize addressing health equity as a goal to ensure effective delivery of programs and to support a more holistic approach to achieving the priority work of the center.
An example of decentralized structure
National Center for Chronic Disease Prevention and Health Promotion
The mission of the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) is to create expertise, information, and tools to support people and communities in preventing chronic diseases and to address persistent disparities in rates of chronic diseases such as cardiovascular disease, diabetes, and cancer, as well as in conditions that affect health such as obesity, teen pregnancy, and smoking. A goal of NCCDPHP is to advance health equity by eliminating racial and ethnic disparities in chronic diseases through its programs, research, tools and resources, and leadership.
NCCDPHP funds programs that target populations that are disproportionately burdened with specific chronic health conditions, such as Racial and Ethnic Approaches to Community Health (REACH), Good Health and Wellness in Indian Country, and the National Breast and Cervical Cancer Early Detection Program. NCCDPHP-funded programs work toward health equity by promoting healthy behaviors, improving access to health care, and linking community programs and clinical supports. Two of the center's divisions, the Office on Smoking and Health and the Division of Community Health, have leadership positions devoted to health equity that work across branches to address health disparities. Most NCCDPHP divisions conduct surveillance that documents and describes the disproportionate burden of disease in racial and ethnic populations and have division-wide work groups that identify and share health equity information and best practices.
Centralized versus decentralized organizational structures
In both the centralized and decentralized structures, assigned staff may participate through workgroups that are tasked with compiling data and information about the epidemiology, research, and programmatic aspects of a particular disease's impact on disproportionately affected populations. Both models may utilize a combination of structures to create collaborative and synergistic functions throughout the CIO. In both models, health equity structures and functions are often linked to strategic plans and accountability measures such as Healthy People 2020 targets.
What may be missing from the decentralized organizational structure is identified and acknowledged leadership that promotes health equity throughout the CIO and guides the implementation of strategies to achieve success in reducing health disparities. There are currently few examples of a comprehensive infrastructure where leadership and engagement for health equity are present at all levels of the organization (center, division, and branch levels).
Complementary health equity infrastructure: Crosscutting committees and workgroups
In addition to CIO-based offices of health disparities/health equity, other organizational entities play a crucial role in sustaining a focus on health equity at CDC. Two key examples are presented in the following text.
Health Disparities Subcommittee of the Advisory Committee to the Director
The Advisory Committee to the Director advises the director of CDC on policy and broad strategies that will enhance the ability of CDC to fulfill its mission. The Health Disparities Subcommittee of the Advisory Committee to the Director is a federal advisory panel of external experts who specifically advise CDC leadership on areas related to health disparities and achieving health equity.
The Health Disparities Subcommittee is composed of national leaders representing a broad range of health equity, public health, and health care expertise. The subcommittee recommends ways to prioritize CDC's activities related to health equity and has provided expert guidance on health disparities and social determinants of health that, in turn, helps reinforce health equity efforts throughout the agency. As such, it is a key vehicle for advancing work on health equity at CDC.
Agency-sponsored scientific work groups
A number of health equity concerns cut across the agency's organizational structures. The Office of the Associate Director for Science, in the agency's Office of the Director, provides oversight for CDC's scientific workgroups that are established to address these crosscutting issues and concerns in order to benefit scientific excellence and accomplish the agency's health protection goals. Currently, 15 scientific workgroups are chartered and approved by the Office of the Associate Director for Science. A number of these work groups are essential to the agency's work on health equity, as they focus on populations, social determinants of health, and/or issues linked to the health and well-being of populations. Two examples are as follows:
* CDC Latino/Hispanic Health Workgroup. The workgroup's mission is to enhance and expand CDC's ability to promote and improve the health of the Latino/Hispanic populations; it is sponsored by the Office of the Chief of Staff, CDC.
* CDC Health and Human Rights Workgroup. It seeks to incorporate health and human rights principles into public health practice and enhance the protection of human rights through the promotion of health.
Together, the Health Disparities Subcommittee and scientific workgroups serve to reinforce and support health equity efforts in the CIOs while offering fresh perspectives, vantage points, and mechanisms for staff involvement in addressing health equity at the agency. These structures have proved invaluable in supporting and advancing the CDC public health mission.
The elements of CDC's health equity infrastructure noted earlier are essential to establishing, enhancing, and sustaining the agency's health equity efforts. However, building and maintaining this infrastructure are not without challenges. In this section, we examine some of the challenges to developing a robust health equity infrastructure at CDC, as these are challenges likely to be met by a range of public health institutions aspiring to work to promote health equity.
Leadership is a key factor in determining the institutional response to health disparities and inequalities. Leaders make the decisions and convey through their language, tone, and examples what is important for achieving health equity. For some public health leaders, addressing health equity is seen as a complementary aspect to the work of public health, rather than as fundamental to achieving the goals of population health. Without strong and visible leadership that advocates for health equity, it is often not possible to ensure that policies and resources are directed appropriately to address health inequalities.
Policies are a driving force for action; they set priorities and valued practices that translate into resource allocation and utilization. Policies must take into account differential health burdens, risk factors, intervention needs, and communication norms of diverse populations. Such policies operate to ensure that funding is distributed to address the greatest health needs, especially given a challenging fiscal environment with multiple competing needs. If leaders are not committed and knowledgeable about health equity, it is difficult to ensure that policies and fiscal resources are accountable to meet the health needs of disadvantaged populations.
Diversity in the workforce is critical to respond to changing US demographic realities and to meet the growing needs of racially and ethnically diverse populations, including diverse populations of women. Often these populations suffer a disproportionate burden of disease, premature death, and injury risk, as they are becoming an increasingly larger proportion of the overall US population.
A diverse workforce is an essential component of an infrastructure that supports health equity. Not only should the workforce be diverse in terms of race, ethnicity, gender, national origin, sexual preference, and disabilities, it should also reflect diverse experience and multidisciplinary expertise in other aspects of public health such as surveillance, epidemiology, social and behavioral sciences, public health interventions and evaluation, policy development, and communications. In addition, a workforce trained and skilled in measuring the effects of social determinants of health is necessary for a clearer understanding of the causes and progression of disease and their impact on health.6,7,19–2119–2119–21 Therefore, staff with such expertise should be an integral part of the public health and CDC workforce.
Similarly, professionals are needed who can develop policies that support the creation of disease prevention and health promotion models. If policies are constructed on the basis of universal strategies alone, we miss important and distinct aspects of population health that are associated with where people live, work, learn, and with whom they interact.22–2422–2422–24
Another important area of workforce expertise is in communications. Poor health literacy is a major barrier to effective communication. As in medicine, public health as a field has not met the challenge of increasing the health literacy of the US population as a whole and, in particular, health literacy among minority and other vulnerable populations.25–2725–2725–27 In addition, the public health workforce needs culturally and linguistically competent professionals with experience in developing tailored health promotion information. Given the persistence of health disparities, it is essential that we increase the number of culturally and linguistically competent public health professionals.
Enhancing health equity infrastructure: Additional considerations
Whether in a local health department, a tribal health entity, or a nongovernmental organization, a robust health equity infrastructure is fundamental to promoting public health and achieving health equity. Here, we discuss additional considerations for enhancing CDC's health equity infrastructure, as these considerations may resonate with readers with similar challenges in their own organizations or organizations with whom they collaborate.
Developing and maintaining a culturally and linguistically competent public health workforce
As previously mentioned, key to workforce diversity is the recruitment and retention of staff from a wide range of cultural and professional backgrounds that is reflective of the demographic realities of the nation, region, tribe, state, or local area. Without diversity, a public health entity's ability to address the needs of all populations in its jurisdiction might be impaired.
At CDC, we are working to improve the less than expected participation of Hispanics, people with disabilities, and military veterans in the CDC workforce. Achieving a diverse workforce is not a challenge unique to CDC. To address this challenge, we suggest the following:
* Improve efforts to increase the number of Hispanics and people with disabilities in the public health and health care workforce.
* Increase the presence of underrepresented groups in leadership positions.
* Support training of the workforce with the goal of increasing cultural and linguistic competence.
* Incorporate health equity training into new employee orientation, and, when appropriate, reinforce in continuing education and other professional development programs.
* Identify and monitor health equity indicators and incorporate progress toward achieving health equity and reducing health disparities into employee performance plans, including those of senior leaders and managers.
* Include knowledge of health equity science and practice in required public health competencies.
Data and information systems
Much of public health work is data-driven and that is certainly the case with CDC. Thus, efforts to ensure inclusion of needed data elements, and collection of that data in a culturally and linguistically appropriate fashion, are essential. Many data systems currently in use, however, have not kept pace with changing US demographics. Therefore, considerations should be given to the following:
* Develop a unified approach to defining and measuring health equity, health inequities, and health disparities, and provide training/technical assistance to staff in applying these concepts in their work.
* Include health equity variables—such as country of birth, primary language spoken, disability status, and sexual orientation—into surveillance systems.
* Ensure that health equity data are collected, analyzed, and disseminated in a timely manner.
To sustain a focus on health equity, it is prudent to align health equity activities with existing accountability efforts such as Winnable Battles at CDC, which are priority public health areas where the agency can make significant progress in a relatively short time frame. CDC has identified 6 domestic Winnable Battles: health care–associated infections; HIV infection; motor vehicle injuries; nutrition, physical activity, obesity, and food safety; teen pregnancy; and tobacco use. Global Winnable Battles are Mother-to-child transmission of HIV and congenital syphilis; global immunization, including polio eradication; lymphatic filariasis in the Americas; motor vehicle injuries; and tobacco use.28
Additional opportunities to promote accountability include the following:
* Share promising practices, innovations, efficiencies, and other lessons both inside the agency and with public health partners.
* Develop and maintain key partnerships to reduce health disparities and promote health equity.
* Include health equity as an overarching goal in strategic plans.
* Include health equity language and guidance in funding opportunity announcements.
Effective and consistent leadership
Expanding, enhancing, and sustaining an effective health equity infrastructure require effective and consistent leadership, that is, leaders committed to implementing programs that address health disparities, and monitoring accountability structures to document progress. Some ways by which leaders can support health equity infrastructure include the following:
* Serve as champions and change agents to address health disparities and promote health equity throughout their respective organizations.
* Provide and communicate a clear rationale—the public health “business argument” to promote a focus on health equity.
* Create governance processes that include internal and external stakeholders to ensure that health equity programs, policy, and research are aligned.
This article offers an historical overview, as well as discussion and additional considerations, of organizational factors that contribute to an effective and robust health equity infrastructure. The focus is on how this infrastructure has been developed and refined at CDC, the nation's chief public health institution, but the principles should be applicable to a wide range of public health agencies and organizations.
In examining the heath equity infrastructure in CDC, providing examples of its current status, and discussing the challenges encountered and considerations for improvement, this article contributes to the growing literature in the arena of organizational structures and functions that support pursuing health equity in governmental public health and other community institutions. The authors hope this discussion will equip public health professionals with a better understanding of the infrastructure needed to support the ever-expanding efforts to ensure health equity for all.