Equitable Funding for the Community to address Health Disparities

Maricopa County is called the Valley of the Sun and attracts over 80,000 new residents annually. The weather and affordable cost of living are significant motivators for people from all walks of life. This annual migration has elevated Maricopa County to the position of 2^nd largest county in the United States, with an estimated 4.5 million residents across 9,224 square miles. Maricopa County holds 62% of the state's population within 24 cities, towns, tribal land, and unincorporated communities. This size propels Maricopa County into the 3^rd largest health jurisdiction in the United States. Given this dynamic, the Maricopa County Department of Public Health must find a way best to serve its residents as the only local health department. In 2021 MCDPH was awarded $26.5 million to address Health Disparities exacerbated by COVID-19. The priority populations engaged via this grant include: American Indian, Black, Native Hawaiian/Pacific Islanders, Hispanic/Latino(a), adults aged 65 and over, individuals experiencing mental illness, and/or experiencing homelessness.

MCDPH has a robust network of partners, which it has leveraged to conduct Community Health Needs Assessments since 2012. However, the COVID-19 pandemic exacerbated MCDPH's partnership network limitations, particularly with smaller community-based organizations (CBOs) that serve the most marginalized community members.

To address these limitations, MCDPH implemented a substantial change to its departmental infrastructure to allow smaller sub-contracted organizations to receive 40% of funding upfront instead of the more typical invoice-and-reimbursement payment structure. This change is intended to make the Request for Proposal (RFP) process more financially feasible for smaller organizations that lack the rolling capital necessary to be successful within a cost-reimbursement structure.   

MCDPH has modified how its program, contracts, finance, and compliance staff work with community organization partners to support this change. Additionally, MCDPH has hired staff to work directly with subrecipient organizations to ensure an optimally collaborative relationship.

·       In January 2022, MCDPH released an RFP for community organizations to address the needs of priority populations disproportionately affected by COVID-19. Organizations were invited to apply for up to $500,000, although most were used for awards of about $250,000.

·       In March, 18 organizations were selected, and contracts were executed in late April. The contracts extend through May 2023.

·       In mid-May, organizations were oriented and submitted scopes of work for their proposed activities.

·       Between May and July, the scope of work was reviewed by CDC to ensure alignment with the NEPS Project. This review process resulted in delays in initial payments to community organizations. Some organizations ultimately could not participate because their proposed activities did not align with CDC's intended scope.

Once contracts were approved by CDC and MCDPH, organizations received 40% of the total award amount to begin their respective projects. These funds were dispersed in early July.

The organizations are presently implementing activities related to addressing the needs of priority populations affected by COVID-19. Partnering organizations submit quarterly progress reports to MCDPH, which continues to provide organizations with technical support, training, and compensation.

In total, $5.6M was distributed to the community through these funding opportunities.

Maricopa County follows Arizona Procurement law, and, as such, all solicitations are released in a manner that is the fairest for all organizations to apply for and receive funding. However, while the process itself is reasonable, it does not address or level the playing field for the inequities that exist in the more extensive population/network of community providers.

Procurement rules also indicate that we cannot collect demographic information about agencies awarded contracts. This ensures that agencies are not discriminated against during the process. However, it also means that we don't have good data about whether funding is distributed equitably across priority populations.

By addressing one of the underlying causes that may prevent agencies from applying for funding (lack of rolling capital), Maricopa County received record numbers of submissions from the community.

By providing funding to agencies in the community that are already working with micro-communities and/or are formed by members of those communities, Public Health has opened up new communication and trust pathways in the community. This will become invaluable in the next pandemic when information needs to reach everyone as quickly as possible and needs to be culturally and linguistically appropriate.  

This funding structure is innovative and new to Public Health and Maricopa County funding distribution. CDC has recognized this as a novel and emerging health practice and is currently working with the Texas Health Institute to document the outcomes of this process and include it in future best practice works.

Collaboration with the community was an essential piece of this new process. Due to procurement restrictions, Maricopa County was not able to get feedback from the community before posting the solicitation documents. However, as contracts were being finalized and best and final offers initiated, MCDPH staff worked directly with the community to ensure that all reasonable proposals could be funded.

MCDPH staff reached out to agencies who were not awarded contracts and provided feedback on their proposals to increase trust in MCDPH and better prepare those agencies for future funding opportunities. MCDPH staff worked with those community agencies and has maintained a relationship towards this end. As contracts were finalized, program and finance staff attended site visits at all new contracts – these meetings were pivotal in creating trust and showing agencies that MCDPH is invested in their communities – not just with financial investments but by investing MCDPH staff as well.

During those meetings, agencies were allowed to provide feedback to MCDPH on the procurement process and to help MCDPH better understand their populations and how we can adapt our practices and services to provide more culturally and linguistically appropriate information.

The following are the intended goals and outcomes of this project:

·       Ensure that smaller community-based organizations have a more equitable and efficient pathway to partnering with MCDPH. The intended goal is that more small organizations will collaborate with MCDPH, thereby ensuring that the most vulnerable community members are served directly by organizations they know and trust.

·       Develop more sustainable, symbiotic relationships between MCDPH and community-based organizations. MCDPH intends to develop region-specific health improvement plans in collaboration with community organizations, which will be advanced by the collaborative processes established through this project.

·       Improve the inclusivity of community partnerships so that partnering organizations fully reflect and include the population of Maricopa County. This will benefit the region in ongoing projects related to general disease prevention and management, including Community Health Needs Assessments, as well as in any future public health crises.

·       In January 2022, MCDPH released an RFP for community organizations to address the needs of priority populations [EJ1] who have been disproportionately affected by COVID-19. Organizations were invited to apply for up to $500,000, although most applied for awards of about $250,000.

·       In March, 18 [EJ2] organizations were selected and contracts were executed in late April. The contracts extend through May 2023.

·       In mid-May, organizations were oriented and submitted scopes of work for their proposed activities.

·       Between May and July, the scopes of work were reviewed by CDC to ensure alignment with the NEPS Project. This review process resulted in delays on initial payments to community organizations and some organizations were ultimately unable to participate because their proposed activities did not align with CDC's intended scope.

Once contracts were approved by CDC and MCDPH, organizations received 40% of the total award amount in order to begin their respective projects. These funds were dispersed in early July.

The organizations are presently implementing activities related to addressing the needs of priority populations affected by COVID-19. Partnering organizations submit quarterly progress reports to MCDPH, who continues to provide organizations with technical support, training, and compensation.

Table 1. Evaluation Questions

Intended Outcome

Related Evaluation Question(s)

More efficient and equitable procedures for partnerships between community-based organizations and MCDPH

1.    What is the perceived degree to which the procedures implemented are more equitable, from the perspective of CBOs?

2.    How have the changes to the procedures impacted the ability of CBOs to partner with MCDPH?

3.    What barriers still exist for CBOs in partnering with MCDPH?

4.    What barriers still exist in the contracting process, from the perspectives of MCDPH?

5.    Were there any factors that made the contracting process more efficient or equitable? If so, what factor(s)? (according to CBOs and MCDPH)

6.    # of weeks between execution of contract and reception of first payment, for this project and for at least one recent project

7.    (Question for MCDPH) Describe the steps involved, timelines, and lessons learned throughout this project.

Strong, symbiotic relationships between community-based organizations and MCDPH

8.    (Question for CBOs) What factors have facilitated a strongly collaborative partnership with MCDPH?

9.    (Question for CBOs) What factors have inhibited a strongly collaborative partnership with MCDPH?

10. (Question for MCDPH) What factors have facilitated a strongly collaborative partnership with CBOs?

11. (Question for MCDPH) What factors have inhibited a strongly collaborative partnership with CBOs?

The development of an organizational network that is representative and inclusive of the MCDPH service area

12. Type, size, and location of sub-contracted organizations

Improved capacity and willingness to partner on future Community Health Needs Assessments and other community-health related projects with MCDPH

13. To what extent is your organization willing to partner with MCDPH on future projects?

14. What factors would facilitate future collaboration?

15. What factors would inhibit future collaboration?

16. Regions represented by sub-contracted organizations

17. Demographics of regions represented

This initiative's sustainability ensures that Grant Administrators working with procurement within MCDPH are aware that they can choose to offer contracts in various ways, including providing funds upfront within reason and clearly outlined goals and objectives. Currently, MCDPH does not plan to offer all contracts using this funding strategy but does plan to centralize grant management staff to ensure proper training on when this funding strategy may be a helpful tool.

MCDPH also created a more structured sub-recipient compliance team within the finance department to monitor fiscal expenses related to these contracts. As money was disbursed before expenses, it has meant that MCDPH has to spend more staff time on the back end monitoring and ensuring compliance. This, too, has been well received by partners in the community as it helps provide transparency to the audit process and helps prepare agencies to apply for future funding opportunities.