Collaborating to Improve Community Health: Workbook and Guide
© The Healthcare Forum, May 1997
Foreword by Tyler Norris

A child is a person who is going to carry on what you started. He is going to sit where you are sitting, and when you are gone, attend to those things which you think are important. You may adopt the policies you please, but how they are carried out depends on him. He will assume control of your cities, states and nations. He is going to move in and take over your churches, schools, universities, and corporations-and the fate of humanity is in his hands.

-Abraham Lincoln

Growing a healthier community is a lifelong process, one that requires our constant nurturing and vigilance. Healthy communities emerge from healthy cultures. They do not come about simply because of a grant, a project, or an assessment and planning effort. These are but tools. When we work toward a healthier community by implementing such tools, we often find that any lasting positive change has more to do with the nature of the leadership and with the process employed than with the product itself. Lessons of sustained benefit in communities point to such factors as how people are meaningfully engaged, how trust and relationships are built, and how the creativity and resources of the community are mobilized toward a shared vision for the future. Leaders cannot dictate or control any of these factors; they can only provide a fertile place for them to happen. As Lincoln reminds us, for the sake of the future we must be mindful of what we stand for and what we invest in, not simply what we proclaim,

Sustaining positive change in community calls for a new form of leadership. Community implies common interest and shared aspiration and ownership. When leaders seek to be in front of the pack with the best idea and then work to get others to buy in, the result is often simply that they have maneuvered others into their camp. Leaders of that genre rarely build true community, despite the short-term boost to their image. This approach is too focused on the leaders themselves, not the people involved. Sadly, this leadership style has contributed to great cynicism and mistrust in our society. It has pushed ordinary citizens, who seek authenticity and substance, to the margins.

Emergent leaders in healthy communities understand that they are not the locus of change. Rather, the locus of real change is in every person, every family, every home, and every workplace, civic space and place of worship. The leader's job is therefore to help unleash the potential in every person, in each of these places. It is at this most personal level that healthy lives and communities develop. A mixed legacy of "best-laid plans" and trillions of dollars spent on programs serves as a testament to the difficulty of building community from the outside. Large-scale change begins as an internal process at home, at work, and at play. This should constantly remind us how and where to focus our energies.

There are clear roles for everyone in creating positive community change. One of the more important roles is in changing how our organizations think and how they allocate resources. These changes include influencing their visions, missions, goals, and resource allocation toward community-based solutions. In many cases, we must begin by redefining the work of our institutions.

For business and industry, building community often means starting within their own frameworks: by operating in a manner that makes a profit but that also builds the broader wealth of the people, community and environment on which they depend. For many nonprof-its and related organizations, building community means moving beyond image, self-preservation, turf battles, and provision of dependency-building services. These behaviors fragment resources, create half-solutions, and sap the will and confidence of people in community. For philanthropy, building community means seeing the value in the "softer" side of community-building activity-much as we would see the raising of a child-as a long-term proposition grounded in building relationships, self-confidence and skills. This decries the one-time, short-term, "show me the outcomes in three years" philosophy that encourages communities to distort the use of their own resources in order to attract others. Although communities should be able to point convincingly to promising results along the way, the real proof may take a generation to harvest.

For healthcare, building community means reallocating resources toward the mission of creating health and well-being, not solely treating disease. It means creating partnerships with schools, churches, businesses and civic groups, and seeing the whole community as an extension of the "health system." At a minimum, building community must begin with providing basic care and preventative services for the tens of millions of uninsured. For the faith community, it means actively carrying out a physical dimension of their spiritual mission. There is no deeper way to understand our creation or to make more relevant the great teachings, than to serve. For the media, building community means educating, not simply informing. Educating implies framing issues in a manner that promotes understanding and action. For government, it requires no longer doing for community what it can best do for itself. It means being responsive to community realities and listening to the community for guidance in fulfilling the government's roles. These roles include serving people as a tool for social change and working to help allocate resources for the common good in a manner that engenders widespread opportunity and equity. Ultimately, building community implies a requirement of citizens to inform themselves, to accept responsibility for what's going on in their communities, and to participate actively in the process of governance.

Today, we hear the call for a deepened sense of community and for more personal responsibility: a desire both to be part of something bigger and for greater accountability. But how do community and accountability grow? Not through such activities as attacking government as the enemy, or seeing such groups as immigrants and the poor as the roots of our problems. This thinking simply frames the problem as "other," rather than "us." Building community health and quality of life must be seen as an investment by each of us in people and in society, an investment that ultimately returns benefit to the economy and us all. This is about community as a fabric, not solely a handful of strong, disconnected threads, each with a separate role.

Collaborating to Improve Community Health builds a foundation of learning from a powerful movement underway in America. It is a movement of multisectoral, comprehensive, community-based health and quality-of-life improvement initiatives that are seeking local solutions to address tough challenges. The movement has its roots in community, not in a national or organizational agenda. At its core are valuing and employing local resources for positive change. It is not about getting more but about effectively using what we have. It implies sharing tools and pooling resources in new ways. It brings together business, government, nonprofit, healthcare, faith community and citizen leaders to address community health and quality of life collaboratively. In the end, this movement's greatest contribution may be in revitalizing our democracy by more meaningfully involving citizens in the work of their community.

This "communities" movement goes by hundreds of names at the local level, but "Healthy Communities" has become one of the more popular. Part of this phenomenon is the universal appeal of health and wholeness, concepts that embrace the physical, emotional, mental and spiritual dimensions of our lives. Especially important is that a healthy community recognizes that most of what creates health has little to do with the medical care system: people's health and quality of life are dependent on many community systems and factors-not solely on access to a well-functioning medical care system. The success stories of healthy communities point to other formal and informal systems that contribute to sustained health: access to quality education, lifelong learning, and skill development; to affordable and adequate housing; to safe places for recreation and for religious and cultural expression; to jobs that inspire and pay a livable wage; to healthy ecosystems; to an honoring of diversity; and to meaningful opportunity for volunteerism and civic engagement.

We are all concerned with crime, drugs, child and domestic abuse, the decline of our inner cities and rural towns, families in crisis, lowering real wage rates and poverty, development patterns of sprawl and congestion, and more. In the face of these challenges to society, the Healthy Communities movement is an organic response. An analogy can be made with the human immune system, kicking into action in response to the presence of disease. Healthy communities build wisdom, power and resilience. Like every community, they have challenges, but they continually find creative ways to address them. They develop thinking processes, community-building skills, organizational structures and resource allocation processes relevant to their emerging realities.

Healthy communities understand power. Power involves who gets to sit at the table when policy and community decisions are made; it involves how those decisions are made and how various resources flow. Healthy communities know how to involve the diversity of their community in making decisions and how to wisely invest their resources in what creates community well-being. They have considered the future for all, not simply the short-term institutional survival of private interests. One can learn a lot about a change effort by looking at the roster of who decides what, and how the budget allocates resources.

It is becoming increasingly clear to leaders from both sides of the political aisle that if the United States is to solve its deepest, most vexing problems, the solution will be found at the local level. Around the country, leaders in business, nonprofit, government, faith, healthcare and the community are successfully mobilizing innovative partnerships that model inclusion and broad-based ownership for outcomes. And as the federal government shifts responsibility to states and communities for solutions and action, the need for communities to produce even better results is increased. The diverse skills and capacities of communities are substantial, but in too many cases they are undervalued, latent and poorly mobilized. Community leaders, and the organizations that inform and support them, must take on this added responsibility to enhance the effectiveness of all members of the community.

Identifying, evaluating and highlighting best and promising practices; sharing tools and stories; and avoiding duplication of resources-all these activities are essential as community initiatives grow across the nation. We see time and again that the real question in community is not what needs to be done but how we will do it effectively. How can we ensure that behaviors and practices are part of how people live and how organizations operate? How can we better use the various assets of the community? How can we better equip those leaders and organizations that are willing to serve as catalysts, conveners, and linkers of resources?

This book contains the combined wisdom of leaders from scores of community-based initiatives across North America. At the same time, congratulations go to The Healthcare Forum and its members, who have long worked to deepen organizational understanding of what actually creates healthier communities, and what creating healthy communities implies for leaders. The book is a celebration of learning from numerous communities across the nation. These communities have found ways to deepen the involvement of diverse community members, create a shared vision based on lasting values, build on their assets, set priorities that enhance the capacity of the community, mobilize tangible action, and measure real progress through indicators that allow continuous improvement.

At the Coalition for Healthy Cities and Communities, we are tracking hundreds of organizations and over 1,200 communities in the United States that in some form are doing "healthy community" work. In its work to directly link thousands of organizational and community efforts with each other in an environment of "peer learning," the Coalition applauds the Best Practices and tools that follow in this volume. These resources must be shared as widely and as effectively as possible for maximum benefit to America's communities. The findings in this book will encourage many thousands of citizens across the country who are working to create measurable health improvement. It can assist them in taking their local initiatives to the next level. And it can help provide credibility to local initiatives by helping skeptical community leaders see that this work is happening around the United States and is producing measurable results.

The idea of a healthy community and the approaches to help bring it about represent a new sense of hope and possibility for the United States. What has evolved over the past decade is a national network of value-laden relationships that set a tone for a new level of health and quality of life. This network has reframed the idea of community improvement. Community-based initiatives cannot be seen merely as projects that must appeal to limited "charity" dollars; they now rightly serve as investment advisors for what creates and sustains community health. Most important, these initiatives have begun to make a compelling case that long-term economic vitality rests on healthy people, a healthy society, a healthy ecosystem. In the end, it is these latter forms of wealth that will define the environment our children inherit and shape who they become.

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