In Buckley, a rural community on the White River in Washington State, elders living in low-income senior housing missed their gardens. They said they longed to get their hands in the dirt, connect with neighbors, taste a tomato warm off the vine, and let the color and scent of flowers trigger happy memories.
In East Tacoma, a historic and multicultural neighborhood in Tacoma, students at Lincoln High School faced long odds to break the school to prison pipeline. Young men of color said their bathrooms, which lacked mirrors, made them feel invisible and like they were already in prison.
The students and seniors are miles apart in their lived experience, political beliefs, and health needs. But White River and East Tacoma are both Communities of Focus, and Tacoma-Pierce County Health Department's (TPCHD's) equity strategy seeks to improve health outcomes in 6 neighborhoods where community members live, on average, 4 years less than those in nearby zip codes.
As in White River and East Tacoma, people in Key Peninsula, Parkland, South Tacoma, and Springbrook also face high rates of poverty. They are less likely to vote or participate in social groups—each Community of Focus has high rates of social isolation and low rates of social cohesion. These neighborhoods include significant numbers of people structurally prevented from traditional voting such as the incarcerated, individuals experiencing homelessness, undocumented people, and youth younger than 18 years. People said they do not feel seen or heard, particularly rural, racially and ethnically diverse, and LGBTQ community members.1
The goal of the Communities of Focus program is to build community power to improve population health through 4 strategies: customer service, partnerships, investments, and civic engagement. TPCHD, alongside its partners in local government, nonprofits, and philanthropy, invested seed funding and backbone support for participatory budgeting (PB) processes in White River and East Tacoma. Over the course of a year or so, community members met in separate processes to review data, develop priorities, and implement projects to decide how to spend public and private dollars to help address the root causes of their health.
Today, the restrooms at Lincoln High School have mirrors so that students can see themselves and hopeful futures. Outside the units of White River Senior Housing Association, raised beds are at a height and spacing to encourage everyone to garden, including residents with wheelchairs. But as meaningful as these projects are, it is the process community members engaged in to create them that can improve their health the most.
What Is Participatory Budgeting?
“Participatory budgeting (PB) is a democratic process in which community members decide how to spend part of a public budget. It gives people real power over real money,” according to the Participatory Budgeting Project, leaders of the practice based in Oakland, California. “PB started in Porto Alegre, Brazil, in 1989, as an anti-poverty measure to help reduce child mortality. Since then, PB has spread to more than 7000 cities around the world. It has been used to decide budgets from states, counties, cities, housing authorities, schools, and other institutions. The New York Times calls PB “‘revolutionary civics in action’—it deepens democracy, builds stronger communities, and creates a more equitable distribution of public resources.”2
PB processes usually last about a year and include 5 phases (Figure 1):
- Process Design, a committee of community members steers the project, creating parameters and engagement plans;
- Idea Generation, the team generates as many good ideas as possible in person and online and gets the community discussing them;
- Proposal Development, community members vet ideas for feasibility and tailor potential projects to have the best possible outcomes;
- Vote, which can be as informal as dropping a token in a cardboard box or as formal as an election certified by an auditor, depending on the audience, time frame, and desired results; and
- Implementation, during which the government or other partners fund and implement the ideas, sharing progress and results with community members who are accountability partners.
Who Is Working for Whom?
The “revolutionary” heart of PB asks government and other authorities such as health care and philanthropy to:
- Recognize that the community members most impacted by health disparities are often the best subject matter experts on their bodies, families, and communities;
- Honor the strength and wisdom in these communities and the value of lived experience of participants as actionable data;
- Cede decision-making authority throughout the process, including final budgeting; and
- Encourage community members to be accountability partners and hold public agencies and community-based organizations accountable as projects are implemented.
PB requires public health professionals at all levels to recognize the imbalance of power involved in traditional funding and budget practices and to honor the power in communities with full decision-making authority:
- Community members set the agenda and act as trusted messengers. They create 2-way communication, roles traditionally performed by community engagement, communications, or program staff.
- Working through the stages of PB may uncover structural racism in systems that must be addressed, often by middle managers in areas such as human resources, finance, and fundraising, to provide the resources for planning and implementation.
- Final decision-making authority from the projects considered to the budgets allocated to the contractors selected resides with community members. Directors of public health, board members, elected officials, and funders who usually dictate terms must lead by stepping back and honoring these processes.
This level of trust and partnership is often new and uncomfortable for health department leaders, staff, and partner organizations. PB practitioners act as advocates for the community members within these systems to ensure that agencies deliver on their promises.
In recent evaluations, PB has proven to engage residents new to public decision-making processes, improve neighborhood conditions, and distribute resources more equitably.3 Community members can respond rapidly and directly to the root causes of health problems, reduce the scale and duration of problems, and improve their feelings of connectedness and well-being. The ongoing sense of community ownership of the project and improved self-efficacy for residents ensure that positive impacts are sustainable and long term. Socially connected individuals live longer and show increased resistance to a variety of somatic diseases ranging from heart disease to cancer.4 This includes more actively coping with stressors, better vascular health shown by lower rates of hypertension, and more effective repair and maintenance of physiological functioning such as better wound healing and sleep.5
Other studies have shown that PB helps allocate resources equitably to democratize towns, making the decisions more transparent, accountable, and efficient. It also nurtured solidarity among groups, reinforced social ties, and promoted the collective pursuit of the common good. PB allows disenfranchised portions of a population to become civically engaged.6 Examples of civic engagement include voting, performing jury duty, and taking part in community demonstrations.7 One recent study demonstrated that people who vote in PB processes are 7% more likely to vote in subsequent elections.8
Projects and Evolution
In 2017, the Centers for Disease Control and Prevention released “Public Health 3.0,” a seminal report of a new era of enhanced and broadened public health practice that goes beyond traditional public department functions and programs. It shows that to improve health and reduce health inequities, we must focus on improving social, economic, and environmental conditions through cross-sector collaboration.9 Historically, public health has had a process deficit in community engagement, which is particularly evident in areas with the highest health disparities. By sharing enough power and capital to bring disenfranchised communities to the table, the health department leaned into PB to increase social connectedness and civic engagement in Pierce County, starting with Communities of Focus.
TPCHD uses the International Association of Public Participation's (IAP2's) Spectrum model (Figure 2) as a guide and use participatory processes to move toward the final stage on the IAP2 Spectrum, “empower.” “Empower” is a flawed term that implies there are not enough assets and power to support these projects. It is the acts of others in the field that actively deny community members the ability to exercise their power. PB is the ultimate expression of “walking our talk” in community engagement. We promise, “We will implement what you decide.”
In 2017, on the basis of its experience leading a parks-based pilot a year earlier, TPCHD led its first full PB projects in 3 schools in East Tacoma. Students in Lincoln High School, Giaudrone Middle School, and Roosevelt Elementary allocated a total of $100000 with seed funding provided by the Robert Wood Johnson Foundation through the Public Health National Center for Innovations. More than 1500 students voted on projects recommended by their peers.
Lincoln High made bathroom improvements. The middle schoolers funded a student lounge, and elementary schoolers funded playground improvements. The projects were implemented by Tacoma Public Schools and their partners, with logistics and communication support provided by the health department. Students voted on formal, printed election ballots produced by the Pierce County Auditor's office, and the steering committee of students took the ballots to be counted and announced. Pierce County Television created a short video of the students from Lincoln High School talking about their PB process. Here is a link to hear the voices of these students in their own words: https://www.youtube.com/watch?v=qecNwgKTx_s.
In 2018, community members allocated $60000 through 3 more projects to improve physical activity and nutrition in East Tacoma, Key Peninsula, and Springbrook. As the Communities of Focus program expanded from 3 to 6 communities, PB projects spread to Parkland, South Tacoma, and White River. TPCHD began to share its lessons learned in publications and at conferences.
Through the Public Health Centers for Excellence, a partnership with Spokane Regional Health District founded in 2010, TPCHD hired full-time PB staff and began consulting with other interested jurisdictions and agencies. For example, the city of Tacoma contracted with the Centers for Excellence on Tacoma Creates, through which East Tacoma and South Tacoma residents are allocating $100000 to support arts, culture, heritage, and science projects in each neighborhood. By the end of 2019, community members in Pierce County had final decision-making authority directing the use of more than $500000 for a wide variety of projects to improve health.
Early in 2020, as the COVID-19 pandemic raged through Pierce County, many staff members were reassigned to emergency response roles. The glaring health disparities in local communities of color and rural communities became more obvious. “Multiple scholarly sources point out that historic social inequities are contributing to the disproportionate toll of COVID-19 in groups that have been socially and economically marginalized, with African American communities being at particular risk.”10
Community engagement went from in person to online in a matter of weeks, a profound change of approach for staff and partners conducting PB. Building long-term trust through participatory processes was more important than ever, but both public health staff and community members experienced a crush of impacts from the pandemic. Timelines lengthened for projects such as Tacoma Creates, but the work continued to evolve and deepen.
As part of COVID-19 community engagement, TPCHD began a series of 19 virtual community listening sessions with groups experiencing the highest rates of infection. The team learned how and where to provide personal protective equipment, promote testing and isolation and quarantine options, and address vaccine hesitancy. Equity officers created the Tacoma-Pierce County Equity Action Network, a leadership collaborative to develop response and recovery strategies and to act as a trusted source of information for the communities most deeply impacted. The Equity Action Network became a central partner to develop strategy and identify trusted messengers to cocreate communication tools and engage the communities with the highest rates of infection.
In June 2020, Tacoma-Pierce County's Board of Health declared racism a public health crisis. The recent killing of Tacoma resident Manuel Ellis, in context of national news of George Floyd and many others, prompted leaders to reexamine policies and practices that increase disparities linked solely to race. TPCHD activated the Race and Resilience Action Response Team to:
- Assess internal policies and procedures to address and reform structures and processes that contribute to race-based decisions and actions;
- Partner with the community to cocreate solutions; and
- Promote policy and system-level changes within Pierce County to undo racist structures.
TPCHD leads with racial justice to improve social, economic, and environmental conditions. Racism hurts the health of all our Pierce County communities. TPCHD strives to be a multicultural organization that centers racial equity and justice. We know racial and cultural differences strengthen our organization and our communities. Among its many commitments is to listen to and engage with diverse communities and make decisions together. Participatory processes such as PB are essential to address the root causes of health disparities and build trust.
Through the COVID-19 and racism public health emergency responses, awareness grew about participatory processes. In summer 2021, the Equity Action Network partners requested American Recovery Act funding from the city of Tacoma to seed PB projects. The city awarded $5 million to launch $1 million PB projects in each of the 5 city council districts. They also invested $250000 in Public Health Centers for Excellence to help facilitate the work and to strengthen and standardize community engagement practices among 4 local governmental partners: the city of Tacoma, TPCHD, Metro Parks, and Pierce County Conservation District.
Next Up: Participatory Policy Making
In December 2020, CoLab for Community and Behavioral Health Policy released “Policies to Promote Health Equity” with support from the Northwest Center for Public Health Practice and in collaboration with TPCHD and University of Washington Department of Psychiatry and Behavioral Sciences:
The emerging literature on health equity is clear that policy formation needs to include community members in empowered and participatory processes so that implementation reflects the actual needs of those most affected by health inequities. These processes might include collaborative design, community planning sessions, participatory budgeting and policy making, or empowered citizen oversight boards.11
TPCHD invests in PB because the process is an opportunity to address the structural issues underlying disparities. Developing policies that reflect real community needs is essential to equity. We expanded to pilot a participatory policy making process (Figure 3).
Through participatory policy making, community members and elected officials partner to address underlying social, economic, and environmental conditions to improve population health. In the pilot process, a diverse group reviewed Pierce County's health disparity data to identify 10 priority policy areas that drive these outcomes:
- Housing affordability and accessibility;
- Economic stability;
- Behavioral and physical health care access;
- COVID-19 care;
- Food affordability and access;
- Education access;
- Healthy community planning and built environment;
- Early childhood development;
- Youth behavioral health; and
- Social connectedness.
The group also established the values it would use to make decisions:
- Restorative—that policies will specifically or primarily benefit communities historically underrepresented.
- Provide an opportunity to improve behavioral health.
- Reduce stigma.
- “Empower” the community as measured by the IAP2 Spectrum.
After discussion, the 10 potential policy areas were narrowed to 3 as the most critical: housing affordability and accessibility, economic stability, and behavioral and physical health care access. Then the group discussed specific policy interventions in these areas that best reflected their values, such as:
- College savings accounts for infants/babies;
- Development standards and inclusionary zoning;
- Community development corporations;
- Tax-free payments for families with children; and
- Housing First programs.
Ultimately, they selected community land trusts (CLTs) as their policy making priority. CLTs are community-based organizations governed by residents and members of the public. They were created in the 1960s by Black leaders in Georgia to reduce evictions of tenant farmers. CLTs acquire property and lease structures to ensure housing affordability. They are encouraged to include ownership and rental opportunities and both commercial and community spaces. They build generational wealth for individuals and families by limiting gentrification and displacement. Community members and elected officials engaged in the process are leading community engagement to identify partners and funding for potential land trust projects in Pierce County.
Innovation and Considerations
PB and policy making processes, while not new, are not widely used in public health. Adapting PB, and applying it as a public health practice, was innovative in Pierce County and can transform engagement practices in many other communities. These practices marry the strengths of health departments in data and surveillance with the lived experience of community members and partners who best know their needs. By working together, public funds are applied more equitably and efficiently and programs and strategies are more likely to be sustained. Over time, the process of sharing power with communities and investing in their priorities builds trust in government and increases community power.
PB meets the Public Health National Center for Innovations' characteristics of innovation12
- PB is “an ongoing, systematic process that can generate incremental or radical change.” The 5-step process has been tested in many contexts and communities. Changing decision-making power from top-down to bottom-up is transformational for most public health agencies.
- It “requires both collaboration with diverse team members and partners, and coproduction with people with lived experience who will be affected by the results of the innovation.”
- PB is “an open process lending itself to adaptation or replication.” Each PB process in Pierce County has used the 5-step process but been adapted to meet the unique needs of communities and funding sources. There is a playbook, but it is dynamic and evolves over time. In this way, it is wildly replicable; yet, no 2 projects are the same.
Several local health jurisdictions around the United States are starting PB processes. As they begin the work, here are a few considerations:
- PB is long-term work. It relies on building and maintaining strong relationships.
- Who is engaged? These processes challenge participation to move beyond “the usual suspects” to center the work around those community members experiencing health disparities.
- Small project budgets are okay but must feel meaningful enough to bring community members to the table.
- Providing compensation, transportation, food, Internet connectivity, and childcare reduce barriers for community members to participate.
- In many cases, public health departments will need to create low-barrier processes to hire, contract with, and pay community members promptly.
- Too often, compensation offered community members to participate is inequitable compared with the public health staff managing the processes, which perpetuates power imbalances.
- Sharing power, especially final authority on budget allocations, requires a high level of commitment and trust from leadership, staff, partners, and funders.
- PB is time intensive and requires a high degree of cultural competence in a wide variety of settings.
- Starting with more traditional participatory planning processes, such as codesign, can lay the foundation for PB and participatory policy making.
Implications for Policy & Practice
- Engaging community members through participatory processes is time and labor intensive but results in culturally grounded programs and services that may be more sustainable because of broad support.
- Participatory processes can be either broad in scope or narrow to address particular health disparities or accommodate funding restrictions.
- No 2 processes are identical. The age and lived experience of community members involved greatly affect communication and mechanics such as voting systems. This requires staff to be nimble and adapt to the unique needs of each project and community.
- Participatory processes require a high level of commitment. In public health, this includes frontline engagement staff, administrative supports in communications, finance and human resources, and executive leadership. They often require external stakeholders such as elected officials and funders.
- While community building is often best in person, emerging technologies such as voting systems for cell phones make it possible to lead participatory processes virtually.
- Money allocated for participatory processes can vary greatly without affecting results. Funds must feel meaningful enough to engage community members. This changes on the basis of age, cost of living, and scale of the problems being addressed.