HiAP Strategy Works in States, Locally to Meet Equity Challenges in COVID-19 Response

December 21, 2021 | Ali Aslam, Bridget Kerner, Adney Rakotoniaina, Alix Ware, Kerry Wyss

Urban train stationWhile governments have faced challenges in adopting a Health in All Policies (HiAP) approach to respond to COVID-19, the impact of the public health emergency across sectors such as housing, transportation, and employment has created a unique opportunity for stakeholders to build and strengthen collaborative systems to address the inequities exacerbated by COVID-19. To aid health departments in their HiAP efforts, the National Association of County and City Health Officials (NACCHO) and the Association of State and Territorial Health Organizations (ASTHO) offer this overview of state and local experiences utilizing HiAP strategies to respond to the needs of their communities during the COVID-19 pandemic.


Throughout the COVID-19 pandemic, racial and ethnic minorities have faced a disproportionate risk of infection, severity, and death from COVID-19. According to the Centers for Disease Control and Prevention (CDC), a noticeably higher percentage of COVID-19 cases for people under 50 are among Hispanic or Latino people compared with the percentage of the total U.S. population. Likewise, data from the COVID-19 Tracking Project show, as of March 2021, Black people have died at 1.4 times the rate of White people. These disparities are reflected in states such as Pennsylvania, where 131.6 per 100,000 Black individuals die from COVID-19 versus only 75 per 100,000 among White individuals, with county level hot spots demonstrating higher rates of disease burden in areas such as Philadelphia County.

In large part, the disproportionate harm caused by COVID-19 may be attributed to generations of discrimination and disinvestment in Communities of Color. Social injustices contribute to more unhealthy housing, air quality, and food access where racial and ethnic minorities live, work, and play. These inequities in social determinants of health give rise to the chronic diseases that increase vulnerability to COVID-19.

Racial and ethnic minorities also face increased exposure to the virus since, as noted by the CDC, they are more likely to rely on crowded public transportation or be employed in essential work settings. As members of racial and ethnic minority groups contract COVID-19, barriers to accessing health care, such as mistrust of the medical community, may also play a role in the increased prevalence of severe infection or death.

The responsibility of identifying and addressing the resulting health inequities does not lie solely with any one entity or government agency. A number of state and local health departments have recognized that meeting the challenges of COVID-19, and building a system that promotes health and equity, requires a collaborative, intersectional approach like the HiAP framework.

HiAP is described by NACCHO as a “change in the systems that determine how policy decisions are made and implemented by government agencies to ensure they have beneficial or neutral impacts on the determinants of health.” When implementing HiAP, health departments can adopt evidence-based strategies, such as developing and structuring cross-sector relationships, incorporating health into decision-making, enhancing workforce capacity, coordinating funding and investments, synchronizing communications, implementing accountability structures, and integrating research, evaluation, and data systems.

Across the country, health departments have adopted strategies for improving equity in their COVID-19 response efforts. While these evidence-based strategies coincide with the HiAP implementation activities listed above, state, and local health departments may not necessarily use the term “HiAP” when referring to their programs. Regardless of the terminology used to describe these efforts, these agencies are aligning principles of health equity with their emergency response strategies to address the disproportionate burden of the COVID-19 pandemic on vulnerable populations.

HiAP Working in the Field

To enhance statewide COVID-19 response, the state of Maryland created a cross-sector task force on vaccine equity. The Governor of Maryland established the task force, along with the Vaccine Equity Task Force Operations Plan to provide a roadmap for community partnerships and inter-agency collaborations. This plan lists building trust and relationships as longer-term COVID-19 response strategies. The state recognizes that immediate activities such as community engagement and information-sharing can help support the long-term goal of improving vaccine access. Ultimately, these efforts could help address challenges of vaccine availability in vulnerable and underserved communities, as well as addressing the underlying root causes that may be exacerbating racial disparities in COVID-19 health outcomes.

The operations plan lists several goals and objectives for achieving statewide distribution of vaccines. At the state level, the plan incorporates HiAP strategies of information-sharing and partnership-building by working closely with LHDs to provide health education in underserved communities. Given that vaccine hesitancy can be a barrier in some regions, engaging with communities to improve health literacy combined with improved availability of vaccines can help to bridge gaps resulting from mistrust of health care or public health workers.

In Virginia, public health officials found that holding community-wide testing events are an effective strategy for identifying COVID-19 cases in hard-to-reach areas. In an effort to promote equity in planning and carrying out testing events and contact tracing activities, the Virginia Department of Health developed the COVID-19 Testing and Contact Tracing Health Equity Guidebook. This guide applies a health equity lens to Virginia’s COVID-19 response and employs HiAP best practices for developing cross-sector relationships, enhancing workforce capacity, and synchronizing messaging.

The guide provides suggestions for private, public, and community-based partnerships when planning an event, along with considerations for equity, such as choosing an accessible location and time. Virginia Department of Health has also made a concerted effort to recruit and provide comprehensive training to staff and volunteers. One way to build trust in a community is to recruit and train people from that same community, so that other community members feel less nervous about getting tested. The guide also emphasizes consistency in messaging. This includes communication materials that are accessible, easy to understand and ADA compliant, as well as being available in different forms and multiple languages.

A local example of using HiAP during the COVID-19 response comes from Allegheny County, Pennsylvania, where staff utilized both formal and informal HiAP strategies. Prior to COVID-19, the Allegheny County Health Department (ACHD) established Live Well Allegheny, an initiative to improve the health and wellness of residents across the county. This initiative was created to improve alignment between the needs of partner organizations and resources in the community. Live Well Allegheny focuses on increasing connections between macro and micro level partners across the county. ACHD utilized its formal partnerships through Live Well Alleghany to ensure continued fulfillment of public health activities when COVID-19 response initially took priority over other health department programs, such as childhood lead poisoning prevention.

ACHD also utilized more informal strategies of HiAP during the COVID-19 response. Specifically, they utilized cross-programmatic relationships to ensure their mission would continue to move forward despite having most of their staff deployed to COVID-19 response efforts. Due to its strong institutional partnerships with communities, ACHD was able to streamline activities and limit duplicative work in areas where there was overlap in programmatic activities.

With rising needs in overdose prevention, sexually transmitted disease, and food insecurity programs at ACHD, violence prevention and chronic disease programs at ACHD were able to identify overlap and provide support through collaboration and joint prioritization of limited resources. Although these connections were made informally, ACHD utilized multiple HiAP strategies including developing and structuring cross-sector relationships, enhancing workforce capacity, and synchronizing communications.

The City of Santa Cruz, California began to incorporate HiAP in their formal processes prior to COVID-19 and plans to continue utilizing HiAP strategies in their COVID-19 recovery. After nine months of exploring HiAP policies and conducting internal surveys, Santa Cruz developed a HiAP Evaluation Plan. This plan created internal policies to review implementation of HiAP principles, and it included a two-to-five-year budget for new diversity, equity, and inclusion trainings. Additionally, the City Council of Santa Cruz began to require every meeting agenda item to include a HiAP analysis, including charts illustrating the HiAP process and metrics for equity, public health, and sustainability.

When looking forward to recovery, Santa Cruz has made HiAP a guiding principle of their COVID Recovery Plan. With the knowledge of the inequitable impact of COVID-19 on racial minorities, Santa Cruz ensures that equity is a central component of the recovery process through formal and informal plans for community engagement. This structure allows Santa Cruz to continue implementing HiAP strategies in communities and work toward recovery in an equitable and healthy manner.


As state and local health departments address the COVID-19 pandemic and the inequities it has exacerbated, a Health in All Policies approach offers a scalable framework that overlaps with many of the key considerations for COVID-19 response, such as coordination, workforce capacity, and equity-centered outreach. With the impact of the pandemic reaching across all sectors and jurisdictions, health departments can readily utilize HiAP strategies to establish a coordinated response through cross-sector partnerships like in Maryland, Virginia, Alleghany County, and Santa Cruz.

Governments have also recognized the need for an enhanced public health workforce capacity to respond to the pandemic, recently exemplified by the $7.66 billion appropriated towards state, local, and territorial health department workforces in the American Rescue Plan Act. HiAP’s emphasis on enhanced workforce capacity to achieve shared goals is demonstrated by jurisdictions like Santa Cruz and Alleghany County, both of which leveraged HiAP strategies within its COVID-19 response structure.

Importantly, HiAP offers a much-needed equity-centered approach as health departments grapple with the health disparities exacerbated by the pandemic.

Each of these HiAP implementation examples incorporate equity into the process through coordinated outreach to communities of racial and ethnic minorities. Likewise, each example demonstrates the importance of a comprehensive approach to COVID-19 response, as well as the feasibility of HiAP to address the current public health emergency and help build the systems necessary to mitigate inequities during subsequent emergency events. ASTHO and NACCHO continue to monitor state and local adoption of HiAP strategies, and both organizations offer resources to aid health departments in their implementation of Health in All Policies.

This article is co-authored by staff from ASTHO and NACCHO, in partnership with the Centers for Disease Control and Prevention’s National Center of Environmental Health and the Agency for Toxic Substances and Disease Registry.