PROVIDENCE – The nature of politics has always been transactional – the study of who gets what, when, and for how much. These days, the growing political tensions in health care and in education in Rhode Island are connected to the increasingly transactional nature of outcomes – the idea that what happens in a classroom and what happens in a doctor’s office are corporate commodities, rather than rights.

More than three years into the recovery from the now-endemic COVID-19 pandemic, the continuing disconnect between community needs and access to resources – and sharpened elbows in the political discourse around access to decision-making around such investments – has become more pronounced.

Communities – particularly those undernourished and underserved communities with the highest levels of economic disruption and unmet health needs – have often found themselves left out of the equation.

Witness the transactional nature of how Gov. Dan McKee and his administration handled the proposed redevelopment of the Cranston Street Armory by Scout Ltd – from the ill-fated business trip in March by two former top McKee officials – DCAMM’s David Patten and DOA’s James Thorsen – to the fundraising lunch in January at the Capital Grille in Providence. The thread running through the entire process was “quid pro quo” – something for something.

In contrast, the burgeoning movement toward greater health equity – and the launch of health equity zones in Rhode Island in 2014 – have recognized the fact that only 10 percent of health outcomes are related to what happens in a doctor’s office, because 10 percent is genetics and the remaining 80 percent is determined by place-based conditions.

Health equity, in turn, puts the focus on who gets to decide where investments in health care get made. Who are the decision-makers?

• When it comes to behavioral health care, for instance, should the decision-maker be Optum? Optum is the wholly owned, for-profit division of UnitedHealth, which is responsible for managing behavioral health for some 90 percent of those receiving health services under the Medicaid through Managed Care Organizations in Rhode Island through Neighborhood Plan of Rhode Island and UnitedHealthcare. We are talking about roughly one-third of the entire population of Rhode Island residents.

• When it comes to defining what community health care needs are worthy of investment, should the decision-maker be the select group of corporate stakeholders chosen by the Rhode Island Foundation? Even to ask such a question can have consequences, particularly when it comes to asking for access to – and participation in – the decision-making process around such investments. The risk is that just posing the question can be seen as hostile – a kind of “biting-the-hand-that feeds you” approach.

Translated, everyone is invited to participate in “Summer Pops in the Park,” a free performance by the Rhode Island Philharmonic at the Temple to Music in Roger Williams Park on Wednesday evening, Aug. 2, to “celebrate the spirit of community,” according to David Cicilline, president and CEO of the Rhode Island Foundation.

But not everyone may be invited to sit down and talk with Cicilline about how the stakeholders are making decisions about future health care investments.

Which makes the results of the recent community “election” held by health equity zones in three Rhode Island cities – Pawtucket and Central Falls and in Central Providence – to determine how to spend some $1.4 million in investments by the R.I. Department of Health that much more remarkable.

As the world turns
ConvergenceRI reached out to leaders of the two coordinating agencies of the health equity zones – Jennifer Hawkins at ONE Neighborhood Builders for the Central Providence Health Equity Zone, and Elizabeth Klinkenberg for LISC RI for the Pawtucket and Central Falls Health Equity Zone – to solicit feedback about how the recent participatory budget voting went.

They, in turn, channeled the questions to their team members in charge of guiding the process. Here is the ConvergenceRI interview with Anusha Venkataraman, managing director of Central Providence Opportunities, ONE Neighborhood Builders, and Rebecca “Becki” Marcus, the Assistant Program Officer from LISC RI.

The answers they provide are filled with a sense of community spirit that celebrates the inclusive nature of the participatory process, where the community members are the participants and decision-makes, not just the spectators or observers.

ConvergenceRI: What did you see in terms of the priorities chosen by residents about where they wanted their money invested?
VENKATARAMAN: The origin of the Nine Neighborhood Fund is that Central Providence Opportunities: A Health Equity Zone [along with the Pawtucket/Central Falls Health Equity Zone] was selected by the R.I. Executive Office of Health and Human Services and the R.I. Department of Health to pilot participatory budgeting processes that address health equity.

ONE Neighborhood Builders [convener of the Central Providence HEZ] was able to complement the initial state investment [funded through Medicaid redesign money] with additional private funds to reach $1 million in funding.

We saw a range of ideas on how to improve health and quality of life throughout the process, from idea generation to project development to the vote.

The ideas submitted and developed into proposals reflect varied but distinctly important social determinants of health, including our built environment and access to transportation, in addition to physical health. Ultimately, the projects selected reflect community priorities.

For instance, one of the winning projects is a peer mental health program that will not only teach young people how to detect the signs of a mental health crisis and provide support to their peers but will also allow those who are trained to train others.

Throughout the idea collection process, community members identified mental health and additional supports for young people as priorities.

Many of the “project delegates” who developed proposals were students at Mount Pleasant High School, who had voiced that their peers don’t always feel comfortable talking to teachers, or other adults, when they are in a mental health crisis. This is why the committee decided to go in the direction of developing a peer support model.

There were also many promising ideas and potential projects that were not advanced because they cost too much or were not feasible or sustainable within the constraints of the process but are nonetheless reflective of community need and interest. We hope elected leaders and funders will take notice and find other ways to make these projects happen!

For example, housing as a way to improve health in the community came up often, and although we agree, building more affordable housing is not something that could be done within the budget of this process.

ConvergenceRI: What is the next phase of the project to keep the community involved?
VENKATARAMAN: As we move into the implementation phase of the process, there are still many ways that residents and communities will remain engaged. We are forming an Implementation Committee composed of residents that served as Steering Committee members or Project Delegates as well as staff from relevant city departments and other partners.

The Implementation Committee will be releasing and reviewing RFPs to select organizations that can implement projects, as well as overseeing the implementation process, including evaluating project success and lessons learned. We intend to continue sharing updates on the process along the way.

We are also finding additional ways to build on the incredible civic energy behind the Nine Neighborhood Fund, whether it may be new opportunities for resident leadership through the Central Providence Roadmap, continuing and leveraging the youth leadership that was critical to this process, and/or connecting residents activated through this process to volunteer opportunities with organizations in Central Providence.

We’ll be hosting an event in August to celebrate both the winning projects and resident leadership that made the process happen, as well as share ways that residents can continue their leadership journey with local organizations. Event details to be released soon.

ConvergenceRI: What improvements would you like to see implemented in the next round of investments?
VENKATARAMAN: As this was a pilot process, we would love to see it happen again so that Central Providence communities can continue to have a direct say in what investments should be made in their neighborhoods.

We have been documenting our lessons learned along the way and are looking forward to sharing our findings with stakeholders, both about the participatory budgeting process itself and other needs identified by residents through idea collection and proposal development

But what we would really love is for participatory budgeting as a process to grow across Rhode Island and its many communities, and become a permanent and institutionalized way for residents, government, and nonprofit organizations to work together to identify unmet community needs and fund the projects that can address them.

Here are the results of the Nine Neighborhood Fund Participatory Budgeting election, with nearly 1,200 votes cast:

LARGE PROJECTS
• Bathrooms and Plants in Our Parks: $368,000 will be directed to install two new composting toilets at Merino Park and increase access to existing bathrooms in Donigian and Davis Parks. In addition, this initiative will support the planting of native shrubs to enhance the beauty of the green space, encourage community use, and protect the environment.

• Lead-Free Water: $330,000 will be directed to provide all households in the Central Providence neighborhoods who have lead-contaminated pipes with an NSF-certified water filter dispenser. Additionally, these funds will help support community education about lead safety.

• Peer Mental Health: $50,000 will be directed to launch a peer mental health training program for high school students in the nine Central Providence neighborhoods. The training will help young people detect the signs that their classmates and friends may be experiencing mental health issues. Students who complete the training will receive a certificate and have the opportunity to train other students in their high schools.

• Improving Our Bus Stops: $132,000 will be directed to add seating, lighting, and additional amenities near approximately four bus stops that currently do not have shelters.

SMALL PROJECTS [All small project budgets are $30,000]

• Life Skills Classes for Youth will provide classes for youth that discuss skills around parenting, personal finance, domestic activities, and other basic life skills.

• Food Bearing Tree Planting will plant 20 food-bearing trees native to Rhode Island [apple, pear, peach, berries, nut trees] around Central Providence to help address food insecurity, lack of green space and tree cover.

• Soccer for Youth will expand the accessibility of soccer playing to more local youth in Central Providence, by providing free access to equipment, outdoor space, and coaching.

• Bike Distribution and Repair will distribute 50 bikes and repair kits and offer bike maintenance and repair workshops to low-income residents of 02908 and 02909.

Participatory budget decisions from Central Falls, Pawtucket
ConvergenceRI: Were the final projects that residents voted on chosen? Was it by LISC?
MARCUS: The final projects up for consideration were chosen by the residents. Participatory budgeting has been used all over the world since it originated in 1989, so we are fortunate to have a well-established process to follow.

The first phase of a participatory budgeting process is to convene a Steering Committee of residents who are representative of the population. The Steering Committee creates the framework for the process, making decisions regarding who can submit ideas, who can vote, how many proposals will be developed, the maximum and minimum amount of funding per proposed project within the total budget and more.

The Steering Committee is also responsible for creating outreach strategies for idea collection and voting. We were lucky enough to have 16 residents step up to serve on this steering committee.

Residents of Pawtucket and Central Falls, ages 14 and up, contributed more than 600 ideas for ways to improve health in their communities. Next, 35 residents took on the role of “Change Agents” and categorized the ideas to develop the viable project proposals. Residents worked together across language and generational gaps – speaking English, Spanish, and Cape Verdean Creole, from middle school age to senior citizens.

The way they did this was by forming six committees based on the categories of the ideas collected: Community and Public Spaces, Education and Employment, Food and Nutrition, Health and Wellness, Housing and Foundational Needs, and Safe Streets and Transportation. The committees of Change Agents sorted through all of the ideas in each category and pulled out the most common themes.

Next, the Change Agents used a matrix with criteria selected by the Steering Committee to determine which of these themes was most vital to public health, most directly served low-income communities of color, and would be most viable. From there, the committees developed out detailed project descriptions and budgets, with input from municipal departments and local non-profits.

The Steering Committee decided that each project committee could submit at most two project proposals, so we ended up with 11 proposals in total as one committee decided to submit just one proposal for the ballot. Each voter could select up to 5 projects, and the two projects which received the most votes are being funded.

ConvergenceRI: Why do you think that concerns about mental health ranked so high in the voting outcomes?
MARCUS: More and more, we’re seeing communities embrace the importance of mental health resources and supports. The cities of Pawtucket and Central Falls were some of the hardest hit by the COVID-19 pandemic.

For people of all ages and especially for youth, the COVID-19 pandemic was a traumatizing event and has had a lasting effect on our community. In many cases, it exacerbated challenges from isolation, financial hardships and school pressures, and at the same time resulted in reduced opportunities for pro-social activities.

The pandemic brought to light the need for community residents to create a healthy environment – and to break down some of the stigma and silence around our health needs. In order to support community members while they face challenges both personal and systemic, mental health resources can provide the vital support that residents need to persevere and thrive.

ConvergenceRI: What changed would you like to see in the next round of investments by voting?
MARCUS: It would be great to see participatory budgeting become institutionalized in Pawtucket and Central Falls. We engaged more than 50 people in leading roles, either as Steering Committee members or Change Agents, and hundreds more in volunteering, sharing ideas, and voting to make their voices heard.

With such enthusiastic resident engagement, we know people are eager to continue to step into leadership roles and drive direct democratic investment. There is great momentum for empowering civic engagement and we’d love to see it continue.

I’d like to see what it would look like to have a process where the funds could be spent over a longer timeline, such as five years, instead of one year. A longer timeline could encourage residents to consider voting for programmatic initiatives as well as one-time infrastructure projects.

For example, when it comes to employment and enrichment opportunities for youth, a longer funding timeline makes space to encourage these programmatic initiatives if you know it will take place over a number of years, and could potentially attract sustainable funding in the long term. Residents have the best ideas for how to improve health in their communities and we’d love to see a sustainable investment in their visions.