Nila Kartika Wati
As the United States navigates its 250th year of existence, the national discourse has increasingly centered on a fundamental reckoning regarding the nature of democracy, the definition of freedom, and the mechanisms through which power is distributed. At the heart of this debate lies the field of public health, which is currently undergoing a transformative shift in how it perceives its role in society. The emerging concept of co-governance is being positioned as a critical framework for addressing the systemic inequities that have long plagued the American healthcare landscape. Co-governance is defined as a collaborative model where government agencies and local communities work through both formal and informal structures to co-create policy, design programs, and ensure effective implementation.
This shift comes at a precarious moment for the nation’s public health infrastructure. Following the unprecedented challenges of the COVID-19 pandemic, a rising tide of political polarization and institutional skepticism has threatened to dismantle decades of progress. For many practitioners, the future of health equity depends not just on medical advancement, but on a fundamental restructuring of governance: determining who sets priorities, who holds decision-making power, and who is invited to the table. By fostering "inside-outside" strategies—where government officials act as institutional accomplices and community organizations serve as leaders—advocates argue that the U.S. can move closer to the elusive promise of a truly multiracial democracy.
The Pandemic as a Catalyst for Structural Change
The COVID-19 pandemic served as both a tragedy and a laboratory for democratic innovation. During the initial years of the crisis, the urgency of the situation forced a departure from traditional, top-down bureaucratic methods. In many jurisdictions, public health workers witnessed a brief but significant move toward collective care. This era saw the rapid expansion of mutual aid networks, the implementation of eviction moratoria, and the distribution of unrestricted cash assistance—policies that had previously been dismissed as politically unfeasible.
A pivotal moment occurred in 2020, as the pandemic intersected with a national uprising for racial justice following the death of George Floyd. This dual crisis prompted more than 250 local and state governments across the United States to formally declare racism a public health crisis. These declarations were not merely symbolic; they signaled a commitment to view health through the lens of structural power and historical disenfranchisement. In cities like New Orleans, Jackson, and Lansing, these declarations provided the legal and social framework for the co-governance models currently being refined.
However, the period following the initial pandemic response has been marked by significant backlash. Data from federal health agencies indicate a concerning trend of "gutting" public health infrastructure. Recent reports suggest that thousands of positions at federal health agencies have been eliminated or left vacant, while funding for essential community services has faced repeated cuts. This ideological shift toward hyper-individualism and the removal of regulatory oversight has created a vacuum that authoritarian-leaning movements have sought to fill. Consequently, public health practitioners are now faced with a choice: allow the field to be used as a tool for institutional exclusion or leverage it as a force for collective liberation.
Assessing the National Landscape of Partnerships
A 2024 national landscape assessment titled Bridges Over Troubled Water, published by Health in Partnership (HIP), offers a comprehensive look at the state of collaboration between health departments and community power-building organizations. The report identified 71 distinct examples of these partnerships across the country, many of which were forged in the fires of the pandemic. These collaborations represent a departure from the traditional "community engagement" model, which often relegates residents to advisory roles with no actual veto power or budgetary influence.
The HIP assessment highlights the effectiveness of "inside-outside" strategies. In this model, "inside" partners—civil servants and department heads—utilize their technical authority and access to resources to clear bureaucratic hurdles. Meanwhile, "outside" partners—grassroots organizers and social movement leaders—provide the political pressure and community insight necessary to ensure policies reflect the lived realities of the population. Over the last decade, HIP has worked with 26 such partnerships through its Power-building Partnerships for Health (PPH) program, demonstrating that when community power is institutionalized, health outcomes improve alongside democratic participation.
Case Studies in Co-Governance: New Orleans and Jackson
The practical application of co-governance is most visible in local initiatives that have successfully translated community demands into law. In New Orleans, the New Orleans Health Department (NOHD) moved beyond traditional medical services to address the economic drivers of health. Recognizing that financial instability is a primary predictor of poor health outcomes, the NOHD partnered with Step Up Louisiana (now ONE, Organizing for a New Economy).
This partnership culminated in a Workers Bill of Rights campaign, which sought to address the "extractive" nature of low-wage labor. In November 2024, the initiative achieved a landmark victory when 80 percent of New Orleans voters approved a modification to the city charter. This change established a Healthy Workplace Program, a system that incentivizes and rewards employers who provide living wages, paid leave, and healthcare access. This case serves as a prime example of co-governance: a community-led demand was researched and supported by a government agency, eventually resulting in a permanent structural change to the city’s governing document.
Similarly, in Jackson, Mississippi, the Jackson People’s Assembly has pioneered a model of "deep democracy." Through a partnership between the Peoples Advocacy Institute and the University of Mississippi Medical Center, the city is implementing community-led solutions to public safety and violence. Rather than relying solely on traditional policing, this co-governance model utilizes political education and collective decision-making to address the root causes of crime. By treating violence as a public health issue rather than a purely criminal one, Jackson is attempting to return autonomy to its residents, allowing those most affected by policy to be the ones who design it.
Regional Innovations and Crisis Response
The reach of co-governance extends into specialized sectors of public health, including migrant rights and environmental safety. In Santa Barbara, California, the Latinx Indigenous Migrant Health COVID-19 Task Force was established to protect farmworkers who were often excluded from federal aid. This task force allowed indigenous leaders to dictate the terms of health outreach, ensuring that language barriers and documentation status did not prevent access to life-saving care.
In Los Angeles, the National Day Laborer Organizing Network (NDLON) has recently applied co-governance principles to disaster response. During the recent wildfires, NDLON worked in tandem with local health advocates to protect cleanup workers from toxic debris and respiratory hazards. These efforts highlight a critical reality: during times of crisis, the government’s ability to protect the public is only as strong as its relationships with the organizations that already hold the community’s trust.
In Kane County, Illinois, the organization Community Organizing and Family Issues (COFI) has collaborated with local health officials to expand mental health and peer support for immigrant families. By moving away from a clinical-only model and toward a community-supported model, the county has seen increased engagement from populations that historically avoided government-run health facilities due to fear or cultural misalignment.
Historical Context and the Professionalization Gap
The current movement toward co-governance is, in many ways, a return to the roots of public health. In the late 19th century, the field emerged from the settlement house movement and sanitation struggles led by community organizers like Jane Addams. During this era, public health was inseparable from social reform, focusing on housing codes, clean water, and labor rights.
However, as the field became increasingly professionalized and academic in the mid-20th century, it distanced itself from grassroots power. Public health became a technocratic exercise, often prioritizing data points over the human experiences that generated them. This professionalization gap created a sense of alienation, where communities viewed health departments as enforcers of state rules rather than partners in well-being. The 2020 racial justice uprisings acted as a "correction," reminding the field that its legitimacy is tied to its ability to address power imbalances.
Implications for the Future of Democratic Institutions
The implications of co-governance extend far beyond the health sector. At a time when democratic backsliding is a global concern, the presence of "institutional accomplices" within the government provides a vital safeguard. When government agencies are deeply intertwined with community power-building organizations, it becomes significantly more difficult for authoritarian directives to be implemented without resistance.
Co-governance creates a "power-building ecosystem" that is resilient to the fluctuations of political cycles and funding shifts. By embedding community leadership into the very fabric of department charters and city ordinances, these partnerships ensure that health equity remains a priority regardless of who is in the mayor’s office or the governor’s mansion.
However, the transition to this model requires what practitioners call "radical humility." For government agencies, this means relinquishing the role of the sole expert and acknowledging that communities possess a unique "expertise of lived experience" that is essential for effective policy. For community organizations, it requires a shift from purely oppositional tactics to a sophisticated "inside-outside" strategy that can navigate the complexities of governance without losing its revolutionary edge.
Ultimately, the future of public health sits at a crossroads. The field possesses the technical authority, the convening power, and the agenda-setting influence to shape the material conditions of American life—including housing, education, and the workplace. If public health continues to embrace co-governance, it may not only achieve its goal of health equity but also serve as a blueprint for how a modern, multiracial democracy can function in the face of 21st-century challenges. The path forward suggests that the health of the public and the health of democracy are, in fact, one and the same.
