Introduction

In North Carolina, an infant’s chance of celebrating a first birthday has long depended on the community where they are born. Persistent disparities in infant mortality underscore the need for coordinated systemic solutions that extend beyond the scope of any single program or organization.

Community Health Assessments (CHAs) are designed to meet that need. They serve as blueprints for collective action, combining data on health outcomes, access to care, and social determinants with community voices gathered through surveys, focus groups, and public forums. CHAs provide a shared, evidence-based understanding of community health needs and offer a framework for setting priorities, aligning resources, and fostering collaboration.

For government agencies, CHAs guide multi-year strategies to improve population health. For philanthropy, they present opportunities to align investments with community priorities, strengthen partnerships, and amplify impact.

Over the past 25 years, local health departments across North Carolina have conducted more than 588 CHAs, an achievement unmatched nationally in scope and consistency. Collectively, these efforts represent:

  • 100,000+ pages of community analysis

  • 1.2+ million hours contributed by community partners and stakeholders

  • 300,000+ staff hours dedicated by local health department professionals

  • $7.1+ million in direct production costs (2019 unpublished study from Kathryn G. Dail at the North Carolina Department of Health and Human Services, Division of Public Health: Cost Analysis of Community Health Assessments in North Carolina)

This sustained effort underscores the leadership of public health and the enduring power of community collaboration, laying the groundwork for tackling complex challenges like infant mortality with measurable, collective impact.

Historical Context

The evolution of CHAs in North Carolina has been shaped by four major movements, each expanding their scope, reach, and accountability.

1. The U.S. Department of Health and Human Services (DHHS) Healthy People Initiative

In the 1980s, North Carolina built on the community diagnosis method pioneered by Dr. Bernard G. Greenberg of the UNC Gillings School of Global Public Health.1 This early approach ranked local health problems using morbidity and mortality statistics. Over time, CHAs matured, incorporating broader community engagement and shared decision-making. By the 1990s, CHAs were well positioned to align with the federal Healthy People goals of 2000, 2010, 2020, and 2030, linking local priorities with national targets and fostering a culture of goal-oriented improvement.2

2. Public Health Accreditation

In 2006, North Carolina became the first state in the nation to require accreditation for local health departments. This pioneering model served as a foundation for the Public Health Accreditation Board’s national standards.3 In both systems, CHAs and Community Health Improvement Plans (CHIPs) are central—not optional—requirements that drive accountability and continuous quality improvement.

3. The Affordable Care Act

The Patient Protection and Affordable Care Act of 2010 (ACA) introduced new incentives for collaboration by requiring nonprofit hospitals to conduct a Community Health Needs Assessment (CHNA) every three years to maintain tax-exempt status.4 Hospitals must also publish an implementation strategy, creating a formal mechanism for health care systems to partner with public health agencies. This alignment between public health and health care providers further embedded CHAs into the health improvement landscape.

4. Results-Based Accountability (RBA)

Most recently, North Carolina has integrated Results-Based Accountability into the CHA/CHIP process. Grounded in Mark Friedman’s framework outlined in his book, Trying Hard Is Not Good Enough, RBA requires measurable, results-oriented improvement and provides tools such as the Clear Impact Scorecard to track progress.5 This approach moves CHAs beyond planning into action, ensuring that progress is transparent, measurable, and meaningful.

Together, these movements have shifted CHAs from static, data-focused reports into dynamic vehicles for community-wide accountability. A pivotal moment came in 2015 when The Duke Endowment invested in CHA implementation, bridging the gap between community-identified priorities and measurable outcomes. By adopting RBA, North Carolina created a natural entry point for philanthropic partners, enabling them to align funding with local strategies, strengthen capacity in underserved communities, and support innovations tied to clear, measurable results.

Baseline Data: Accountability in Community Health Improvement Plans

A 2019 pilot analysis of 471 measurable outcomes across 100 local health department CHIPs revealed substantial challenges: 59% of outcomes were never reported, despite accreditation requirements; of those reported, 24% were unclear or uninterpretable; and among outcomes that could be assessed, 12% were not achieved, 4% partially achieved, and only 2% were fully achieved.6

These findings highlighted a critical gap between planning and accountability, prompting the North Carolina Department of Health and Human Services (NCDHHS) to make RBA the statewide standard for community health improvement planning. Importantly, community health improvement efforts were formally linked to “Healthy North Carolina 2030” and the North Carolina State Health Improvement Plan (NC SHIP), ensuring alignment between local strategies and statewide population health goals.7,8

Methods and Approach

Following each CHA, local health departments collaborate with community partners to develop CHIPs that outline strategies to address identified priorities such as mental health, chronic disease, maternal health, and housing.

North Carolina piloted RBA in 2015 with 16 western counties.9 By 2020, the state formally adopted RBA to strengthen accountability and improve outcomes across the CHA–CHIP process. RBA distinguishes between population-level results (broad outcomes for all residents) and program-level performance (specific contributions of individual initiatives). The framework begins with the desired result and works backward to identify strategies and measures. Rather than rushing to action, RBA employs a disciplined, data-informed approach that asks a core set of questions to clarify “wicked problems” and identify evidence-based responses.

Statewide implementation follows a three-tiered model that engages:

  • The current public health workforce

  • The emerging workforce (students and early-career professionals)

  • Partner workforces (health care systems and community-based organizations)

This phased approach is aligned with the North Carolina Local Health Department Accreditation cycle, which requires CHAs at least every 48 months. Despite the challenge of launching during the COVID-19 pandemic, full statewide implementation was achieved in 2024, an accomplishment that included adoption by ECU Health and several community-based organizations.

By embedding RBA into the CHA–CHIP process, communities across North Carolina are now better equipped to address complex systemic challenges—so-called “wicked problems”—with a shared framework that clearly links local strategies to population-level outcomes.

Results

To advance CHAs and CHIPs statewide, North Carolina has invested in a comprehensive RBA infrastructure that includes:

An RBA certification for faculty, creating a trained cadre of instructors to build local capacity.

A web-based RBA course, delivering flexible, on-demand training for public health and community partners.

Operationalizing “Healthy North Carolina 2030” goals, translating state-level objectives into actionable, measurable strategies.

The Healthy North Carolina 2030 Resource Center, serving as a central hub for tools, templates, and guidance.

Statewide training and technical assistance, ensuring consistent implementation and skill development across jurisdictions.

Clear Impact Scorecard school, offering hands-on training in performance management software.

Updated CHA guidebooks and CHIP tools, providing standardized, RBA-aligned resources for local use.

A public-facing North Carolina data portal, expanding equitable access to population health data for decision-making and transparency.

As a result of this infrastructure, every local health department in North Carolina now tracks CHIP strategies using plain-language performance measures—“how much, how well, and better off”—which are accessible to the public through the NC CHIP Scorecard.10 This transparency strengthens accountability, builds trust with communities, and allows decision-makers to monitor progress toward achieving “Healthy North Carolina 2030” goals.8

Looking Ahead

With a fully operational RBA infrastructure, North Carolina is positioned to lead the nation in community health accountability. In fall 2025, CHIPs from 86 local health departments (covering all 100 counties) will undergo reassessment to evaluate the impact of RBA on reporting quality and health outcomes.

Future priorities include integrating hospital CHNAs more fully in the Clear Impact Scorecard and inviting other sectors to engage in community health improvement planning. Several North Carolina Councils of Government have used the Clear Impact Scorecard to track the performance of economic development strategic plans.

Both NCDHHS and the North Carolina Area Health Education Centers (NC AHEC) acknowledge remaining challenges like workforce turnover and sustaining momentum for the RBA movement. Recognizing the value of public-private partnerships, we hope to diversify funding across multiple sectors and identify opportunities to strengthen data systems, foster cross-sector collaboration, and support local capacity-building.

The vision remains clear: all people in North Carolina thrive in healthy communities. North Carolina is creating a model for how states can translate health assessments into meaningful, measurable change.

Acknowledgments

The author gratefully acknowledges the many partners who have played a significant role in advancing the infrastructure to support accountability in community health assessment and improvement.

Special thanks are extended to Mark Friedman, creator of Results-Based Accountability (RBA), for sharing his vision through plain language and a common-sense framework for measuring progress. His work has been foundational to this effort.

Appreciation is also extended to individuals and organizations whose contributions have been invaluable, including: Chris Collins, The Duke Endowment (retired); Liz Starr, HopeStar Foundation; Hugh Tilson, North Carolina AHEC; Lorrie Basnight, Eastern AHEC; Claire Mills, Elizabeth City Office, Eastern AHEC; Laura Webb, HNC 2030 Resource Center; Erin Shoe, Region IV NC Local Health Directors’ Association; The RBA Project Team at Eastern AHEC; The CARES Project Team at the University of Missouri; Will Broughton, NC Division of Public Health and formerly with the Foundation for Health Leadership and Innovation; Roseanne Simmons, ECU Health.

Their collective expertise, dedication, and partnership have been essential to the progress and success of this initiative.