Inclusive Contracting: Successes to Advance Breastfeeding Equity

July 14, 2021|11:22 a.m.| ASTHO Staff

Though now an illegal practice, government contracts, policies, and practices have generally excluded women, and Black, Indigenous, and people of color (BIPOC). Still, practices and existing structures continue the inequitable distribution of all contracts. Governmental and non-governmental (business, private, and foundation) grants and funding should benefit the communities they serve while being proportionate to the communities' demographics.

This is where inclusive contracting comes in. Inclusive contracting creates an environment for organizations owned and run by women and BIPOC to participate in a contract fully. Inclusive opportunities to use funding can increase wealth accumulation potential in communities of color, such as new sources of income and jobs, bolstered community and business partnerships, and better health outcomes.

To address institutional and structural barriers and to achieve sustainable change, funding announcements and contracts should recommend or, if possible, require a health equity focus, equitable funding opportunities, data collection, and evaluation and process measures. Implementing these recommendations or requirements can support multi-level, multi-sector transformational change to advance health equity.

Strategies and Partnerships—State Highlights

ASTHO, with support from CDC, awarded funding in 2019 to nine agencies and organizations to collaborate with partners in implementing innovative strategies to advance breastfeeding equity. Partners included local health agencies, community-based organizations, state and local breastfeeding and obesity prevention coalitions, healthcare facilities, universities, and hospital associations. To advance equitable contracting, collaborations, and partnerships, the request for proposals (RFP) emphasized traditional and non-traditional partnerships. Applicants could choose to partner with an entity—whether coalitions, universities, or local organizations to apply as bona fide agents on their behalf. The RFP also encouraged project proposals that incorporated transformational approaches when addressing health equity. Transformational approaches cross multiple institutions, creating community-based solutions developed by the community, which create long-term shifts in cultural values integral to advancing breastfeeding equity. Below are some state highlights:

  • Alaska implemented a program focused on developing long-term support for systemically marginalized breastfeeding mothers and their families in the greater Fairbanks area before and after inpatient delivery. Alaska created an advisory board composed of systemically marginalized breastfeeding mothers, a lactation specialist, a women and infant services nurse, and a pediatric hospital staff member. The advisory board provided information on how best to support systemically marginalized families during their breastfeeding journey.
  • Arkansas is working to improve the continuity of care for breastfeeding mothers and infants served by early childhood education (ECE) centers. This non-traditional partnership addresses health equity by focusing on ECE programs in medically underserved counties. The counties include low median incomes, where mothers face breastfeeding barriers related to socioeconomic status, low education, access to care, environmental conditions, and other factors.
  • Colorado designated a local organization, the Center for African American Health (CAA Health) as its bona fide agent. Through this partnership, the project provided advanced lactation training to BIPOC, created support groups for families, and hosted educational opportunities for community health workers and families. At the state level, Colorado reimburses grantees (rather than providing funding upfront). This policy creates a barrier to organizations that may not initially have the cash flow or capital to provide start-up activities without additional financial support and resources. As a bona fide agent, ASTHO paid invoices to CAA directly, bypassing the inequitable state policy.

Guidance for Inclusive Contracting

There are various ways state public health agencies can improve practice and policy strategies for inclusive contracting. Recommendations include:

Expand Inter- and Intra-Agency Operations to Promote Health Equity

  • Acknowledge past discrimination in contracting to support efforts that include, but are not limited to, self-awareness, understanding, and building trustworthiness.
  • Implement health equity education opportunities, including workshops and training on the importance of equitable language in funding announcements and contracting, and how to change inequitable funding processes and policies.
  • Create/use a framework (e.g., guiding principles, shared value statements) for cultural change to ensure all people share the same understanding and expectations around non-discrimination and equity.
  • Modify grants management system and structural changes to allow for inclusive contracting, as necessary.

Develop the Contracting Process with a Health Equity Foundation and Lens

  • Embed health equity language through the RFP template for standardization.
  • Explicitly declare the extent of the disparity or inequity.
  • Require specific demographic characteristics of the focus population (e.g., race, gender, ethnicity, religion, income, education, home ownership, sexual orientation, marital status, family size) and the standard use of census geography.
  • Provide references to methodologies for interventions with social determinants of health and other planning documents.

Disseminate the Funding Opportunities Equitably

Improve Grant Award Practices and Processes

  • Support educational opportunities for state agencies and their multi-sector partners on the benefit of community collaborations.
  • Ensure funding opportunities contain or connect to various programs such as capacity-building, innovative, and evaluation programs.
  • Encourage approaches that provide an infrastructure for sustainability.
  • Establish health equity standards in review criteria.

Inclusive contracting advances economic equity and bolsters opportunities for equitable outcomes in communities that have historically and continue to be underresourced. Contracting equity policies and programs should collaborate with cross-sector partnerships and encourage multi-faceted and comprehensive programs to dismantle complex systemic barriers. ASTHO’s breastfeeding contracting process leveraged methods to incorporate health equity into the funding opportunity. The ability to improve inclusive language processes and practices ensure grantees address the population's needs most impacted, improve health outcomes, and ultimately achieve health equity.


Aika Aluc, MPH, is a senior analyst with the maternal and child health team at ASTHO
Ify Mordi, MPH, is the director of maternal and infant health improvement at ASTHO
Melissa Lewis, MPH, is the director of health equity at ASTHO
Evangeline Crawford is the director of grants and contracts at ASTHO