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November 15, 2021
By vaccineequity

Blog: Addressing Systemic Inequities and Racism in Community-Based Organization Funding

It has never been more critical to document and amplify lessons learned from our nation’s pandemic response in order to shift how we perceive, value and fund CBOs and CBWs.

Authors are members of the Vaccine Equity Cooperative and/or the Community-based Workforce Alliance

Alex Fajardo, Executive Director, El Sol Neighborhood Educational Center
Alexandra Quinn, CEO, Health Leads
Dr. Alexandre White, Assistant Professor, Johns Hopkins University
Venus Gines, President & Founder, Día de la Mujer Latina
Denise Octavia Smith, MBA, BS, CHW, PN, SFC, Executive Director of National Association of Community Health Workers
Madison Taylor, Graduate Policy Assistant, Community Health Acceleration Partnership

The COVID-19 pandemic has both strained and exposed our country’s deep under-investment and under-valuing of community-based organizations (CBOs) and workforces (CBWs) – including food banks, churches, shelters, health advocates/navigators, Promotores and others – like never before. These organizations and community members have long played a critical role in delivering services and support tailored to address the downstream impacts of systemic racism and improve living conditions for people in their local areas. While organizations like health systems and academic institutions hold more power, influence and capacity, CBO and CBW proximity to and trust with community members, understanding of local cultures, and expertise in navigating local systems launched CBOs and CBWs into the spotlight as key to our pandemic response and recovery. 

New and unprecedented funding streams from national policies like the American Rescue Plan and the CARES Act, as well as many other private investments, are a step in the right direction, but administrative barriers and limited funding models mean that many of these dollars remain inaccessible to CBOs. But they have also further revealed the deep-rooted systemic racism and power imbalances that continue to strip CBOs and CBWs of their ability to effectively lead, innovate and resource in support of their local areas. 

It has never been more critical to document and amplify the lessons learned from our nation’s pandemic response in order to shift how we perceive, value and fund CBOs and CBWs. These lessons will enable us to not only more effectively respond to and weather the storm of the current and future pandemics, but also establish strong, proactive, locally-focused networks of health and equity through collaborations. 

Closing Short-term Funding Gaps Can Build Long-term Trust 

Two significant and related problems are impacting grants to CBOs in the short term. CBOs and CBWs have been critical to enabling every part of pandemic response and vaccine uptake. Examples across the U.S. are countless, but one includes Yuma County, Arizona, where local harvesting companies partnered with public health officials to vaccinate migrant workers and its Latinx community, working with promotoras and community partners as trusted messengers enabling different approaches to break down health literacy barriers. This work has been successful on several fronts from culturally competent care to enabling an increase in vaccine update. The first challenge is that while locally-based organizations and workforces are able to provide services in very complex settings where they know community members best, they may not have the infrastructure to keep up with all of the operational aspects including raising funds to sustain these critical efforts. 

Second, larger entities like universities, municipalities or national NGOs are applying for and receiving federal grants where they depend on local services to provide direct care, yet these intermediaries are not compensating CBOs in a timely manner or at all, under the guise of not meeting operational standards set by the intermediary. In many cases, these larger organizations are not recognizing the CBOs effort and partnership under the  Community-Campus Partnerships for Health (CCPH) principles. Since January 2021, hundreds of CBOs or groups of CBOs have reported cases of larger entities failing to deliver contracted payment for services provided on the ground. The most recent accounts include NIH-funded projects in three geographic regions where local CBOs have yet to be paid for months of services. 

This was not uncommon prior to the pandemic, but only exacerbated by the immense responsibility and pressure put on CBOs to deliver in a time of crisis. One county required a big refund from CBOs because timesheets were in Spanish. In another, grant auditors did not validate some expenses because some of the attendance sign-in sheets were adjusted using a White-Out pen corrector. In another case, the grantor requested a big reimbursement from a CBO four years after the grant ended, because the timesheets did not match with mileage logs. Withholding payment from Black, Indigenous, Latina/o/x and AAPI community members for work rendered is racism, even if inadvertent, even if inadvertent, and a deep lack of understanding of CBO challenges and unwillingness to invest in long-term sustainability of CBOs.

This is largely due to the reality that legal and operational systems that enable health care and public health were not built to support smaller, more proximate community organizations to deliver services. They were built to hold up larger organizations and institutions with the money and time to adhere to laws or standards that are not often clear, or can’t fund the capacity to adhere to those standards. American public health systems developed alongside large scale urban and rural infrastructure projects. The development of sewer systems as well as infectious disease control for illnesses such as malaria saw massive increases in overall public health. However, since the 1970s, public health expenditures have continued a consistent decline as a share of public expenditure. 

Advocate Urgently Today, Rebuild CBO Grantmaking for Tomorrow

While CBO payment is a deep-rooted and long-standing problem, urgent advocacy at every level now can ensure CBOs and CBWs are compensated for their invaluable work. To guide future CBO partnerships and funding, here are a set of co-developed principles to improve current and future grantmaking and grant auditing processes.

Invest in Community Infrastructure
CBOs are at the center of the community-based workforce, but we have not invested in building their capacity to improve the nation’s health. Unique compared to academic, healthcare, or governmental public health departments, CBOs have the deepest relationships and know-how for training, employing, supervising, and deploying the CBW efficiently and equitably. It’s time for funds like HRSA to create and support a National Consortium of Resource Centers for CBW Workforce Development and CBO Capacity. Beyond helping to coordinate data and evaluation for the CBW workforce, these federally-funded regional resource centers would help CBOs to significantly build their capacity to a) equitably train, employ and manage a diverse CBW and b) partner with other sectors including local health departments, county health care systems, Medicaid and Medicare managed care plans. Other HRSA-supported infrastructure models and cooperative agreements, including the National Consortium of Telehealth Resource Centers,  serve as analogs and demonstrate the agency’s ability to help develop the infrastructure for CBOs and the CBW.

Co-Design Contracts and Initiatives to Build on CBO Assets and Mitigate Barriers
CBOs are often the best service providers because leaders and staff know the local area and can tailor services based on that community. They offer deep social assets and community organizing abilities. Any entity that is working with local CBOs must first understand the challenges of the CBOs – lack of infrastructure, cashflow, the multiple roles executive directors must play. Then, as part of the contracting process, co-design to mitigate any barriers that may come up due to lack of infrastructure. Design initiatives and objectives alongside CBOs to make the largest impact, including how money should be distributed and the funding structure which will allow the CBO to make the largest impact (this may include up-front payment, purchasing supplies, etc). Adapt funding processes and eligibility criteria to create an environment where communities with the greatest need benefit from funding first.

Provide Direct, Flexible, Sustainable Funding for Capacity-Building and Grant Management
Today, universities receive anywhere from 35-68% of indirect funding, compared with 10% for CBOs. Prioritizing long-term/sustainable and flexible funding allows for CBOs to invest in their capacity, workforce, and building trust and connection in their communities, recognizing the time and energy that goes into preparing and maintaining a community based workforce as well as planning for and managing the grant. Grants should also allow for flexible funding for increasing indirect rates, not just compensating for direct services, and ongoing support and technical assistance on fiscal documentation required from the grantor even before the contract starts. Build capacity for funding coalitions, with memorandums of understanding amongst CBOs that want to team up and apply for funding together.

Foster Strong Relationships with Local Government Officials
Funding from programs like ARPA funnel through state and local officials who are critical to determining which organizations are eligible for this funding. Close ties between CBOs and government officials, and a shared understanding of the value of community-based work, can help these funding streams become more accessible. Most government funding comes through direct service contracts with a county or local municipality, highlighting the need for strong CBO and local government partnerships. CBOs may consider forming funding coalitions, complete with memorandums of understanding and a primary fiscal agent, to amend existing service contracts to include COVID-19 response work reimbursable under APRA, and generally tackling government funding challenges together. In addition, these relationships could open doors to training for county/government auditors on how to do CBO contracts audit vs. government audits. Today, some auditors require three quotes for a box of print paper. 

In addition to these principles, we also encourage people to read and sign onto the Community-based Workforce (CBW) Principles. Often CBWs are the people providing the services, and hiring, managing and supporting these essential community members is critical. 

Stronger Support for Community-based Organizations Creates Path to Health Equity

The same academic institutions that rely on community partners to translate, convey and disseminate academic knowledge and data, often make it extremely difficult for community organizations to gain access to funding and reimbursement within a reasonable time-frame,

to engage the populations they serve daily and to do so in real time. But institutions have the opportunity to fully support community stakeholders who often execute the lion’s share of the important work of reaching and intervening with distressed populations to bring about improved health outcomes and health responses in communities. 

We’ve known long before the pandemic that CBOs and CBWs are crucial to the health of every community – especially communities of color. During the pandemic, they have risen to the occasion as key trust-holders with innovation and commitment to their communities, even in the face of limited resources, data and decision-making power. It’s past time the organizations with money and power rethink and root out racism in the systems we need most. We urge you to join us in the short-term advocacy and long-term systems change that demands a strategic, collective movement that partners local CBOs, government, philanthropy and community members with a single mission of enabling health equity.

Acknowledgements

Thank you to the teams at the Community-based Workforce Alliance and Institute for Healthcare Improvement for contributions to this article.

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