Pathways to Greater Partnerships and Investment at the Health-Water Nexus to Improve Community Health Outcomes and Resilience
by Tee Thomas, Vice President
Part 2 of 2 (Read part 1 here | primera parte en español)
People are healthier when they have access to clean water and natural infrastructure amenities. This simple statement seems obvious, and is central to the Clean Water and Safe Drinking Water acts. It also is a core foundation of public health departments at the federal, state, and local level.
U.S. EPA reports indicate that communities with green stormwater infrastructure see evidence of more physical activity and lower obesity rates, thereby reducing other chronic illnesses including heart disease, high blood pressure, stroke, diabetes, arthritis, and some cancers. Proper wastewater treatment also is critical for control of infectious diseases that cost billions worldwide annually.
But if it’s so simple, why aren’t we identifying community health needs (e.g., hypertension, diabetes, asthma) that are tied to clean water and natural infrastructure amenities like trees and green space, and forecasting water management interventions to make them healthier? And why aren’t we measuring the actual health outcomes of our water and natural infrastructure investments to see if anyone is better off?
At Quantified Ventures (QV), these questions drive us forward. We work at the juncture between health and water and believe that it’s our charge to forge a roadmap for better connecting water utilities and health sector entities (e.g., insurers, public health departments) for more intersectional, outcomes-driven, and cost-effective investments.
We do this because it's better for human and environmental health, and also because it's good business. That said, more work is needed to effectively convey the positive impact for private sector actors. The opportunity ahead is to engage private health sector companies more efficiently and proactively in the planning, development, and financing of water infrastructure upgrades.
Given the correlation between clean water, public health, and local economic development we can make a compelling case to both private and public institutions that they should transition from being observers to supporters - and even potential water infrastructure investors. By understanding their mission-aligned priorities and goals, we can more effectively engage their support and augment government funding streams that are necessary but not sufficient to pursue sustainable (and replicable) system-wide infrastructure projects that deliver better health outcomes.
Identifying the population health benefits of public infrastructure projects opens the door to more public-private partnerships – offering private actors an opportunity to finance solutions that close budget gaps for public infrastructure AND drive measurable environmental and health improvements.
Our work with Medicaid health plans offers a useful example. Like public health departments, these organizations share an interest in clean and safe drinking water as an essential ingredient to the health of the members and communities they serve. Crafting narratives that help them to see investments in water and natural infrastructure as yielding dividends for member health presents an opportunity to test and evaluate community investment in infrastructure solutions.
Because the evidence base is still emerging, a way to get the ball rolling is to connect with the philanthropic and community investment arms of healthcare organizations with mission-aligned incentives to deliver resources for community health and equity improvements. We have been able to make progress by:
Engaging community members and allied organizations to better understand their health-related needs and concerns, and to estimate their associated impact on local healthcare organizations.
Mapping clear connections between the benefits of water infrastructure investment and improvements in prioritized health outcomes, with a focus on the impact for local healthcare organizations’ members and/or patients.
Understanding local healthcare organizations’ priorities and demonstrating how their potential investment could positively impact their community health and equity goals.
Characterizing the methods and metrics that can be used to assess the health effects of water infrastructure investment, both in the short (1-3 years) and longer (4-10 years) term.
The benefits of this approach are numerous and compelling, but require robust data collection and measurement efforts to fill in blind spots for local government decisionmakers like city planners and county health departments, and to confirm the investment case for private healthcare organizations needing to assess the economic value of delivered health outcomes. Planners can optimize the type and location of public projects such as green stormwater infrastructure and public parks to produce dual green-social benefits. County health departments can target programs and outreach to neighborhoods with the greatest disparities. Most important, both the green- and social-serving arms of local governments can coordinate their efforts to improve public health in a data-driven way.
This approach lends itself to a financing strategy that centers community resilience and works in tandem with community organizing, policy development, and leadership development. Collaboration may initially take the form of grant support, in-kind resourcing, and access to health-related data, and then evolve toward payment for outcomes achievement as the local evidence base for the environment-health nexus is established. These outcome payments could go toward the maintenance and upkeep of infrastructure solutions, ensuring their sustainability and long-term value to communities.
Philadelphia and Milwaukee are home to active projects at the water-health nexus.
Green stormwater infrastructure installation in Philadelphia (image source: Philadelphia Water Department)
In Philadelphia, Quantified Ventures is working with Greenprint Partners, the Philadelphia Water Department, and other stakeholders to advance a health-first green stormwater infrastructure (GSI) plan. This includes designing and siting GSI to encourage physical, social, and restorative activity that leads to improved health outcomes. There are active efforts to engage local health plans, foundations, and providers as co-investors in the GSI to bring their health expertise to bear and increase the financial capacity to optimize infrastructure for health outcomes. The specific outcomes of interest relative to exposure to GSI in Philadelphia are COPD, cardiovascular disease, depression, anxiety, asthma, obesity, and diabetes. The hope is this project can provide a replicable blueprint for others to prioritize health in green stormwater infrastructure design.
Images from Milwaukee’s Kinnickinnic River Watercourse Management Project (image source: Sixteenth Street Community Health Centers)
In Milwaukee, the Sixteenth Street Community Health Centers are working with a number of local public and private stakeholders to reduce flood risk, improve public safety and health outcomes, and create high-quality riparian and aquatic habitat through the restoration of the Kinnickinnic River. This ambitious multi-sector partnership will restore the natural flow and flood retention of river, which in turn will improve public health. In one step of a 15-year process, Pulaski Park was refurbished to provide more usable community green space and the concrete channel that controlled the river replaced to enable the river to return to its natural flows.
Other examples of novel multi-sector projects at the water-health nexus are the Proyecto ENLACE del Caño Martin Peña in Puerto Rico and Oregon Water Futures.
Let’s turn back to the public sector opportunities. While there are a number of ways that state and federal water infrastructure programs can support more investment in the health-water nexus, we recommend three key near-term opportunities:
Embrace flexibility to spur innovation at the state level: As healthcare organizations and municipal water utilities increasingly coordinate to improve investments, there is an opportunity for state and federal policy and programs to allow for innovation in this space. This could be in the form of research and development grants, loan forgiveness for projects seeking to demonstrate an environmental and health outcome, or flexibility in procurement language to use outcomes-based approaches.
Recognize intersectionality between environmental and health issues through more federal cross-agency collaboration: One primary way this could be realized is to evaluate and enable mechanisms that support federal, state, and local investment in outcomes for water and health. Currently, most investments through the USDA and EPA State Revolving Funds (SRFs) are focused on low interest loans, forgivable loans, or grants to complete projects. Historically, these are siloed investments. Creating additional categories of projects that deliver important outcomes associated with health, environmental, and resilience targets – as the USDA moved toward with their Partnerships for Climate-Smart Commodities funding awards – can allow for more holistic project implementation and better results.
Enhance collaboration and systems-level planning to move the needle on the health-water nexus: State and local health organizations and authorities with vested interest in containing medical costs can be engaged early and often in understanding where and what types of water infrastructure projects will be developed, and the associated health outcomes. Additionally, we must meaningfully incorporate the interests and needs of the local community in decision-making to ensure equitable and sustainable water infrastructure. Providing the community a seat at the table helps to ensure that fiscal allocations for development plans consistently keep residents front of mind and provides numerous social benefits, including enhancing protection against the potential for resident and small business displacement.