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Context: Local health departments (LHDs) and their partners are critical components of the fight for racial health equity, particularly given the variation in levels of, and pathways to, inequities at the local level., Objective: To inform continued progress in this area, we qualitatively examined the development and implementation of equity-related plans and initiatives of LHDs within 4 large US cities: Baltimore, Boston, Chicago, and Philadelphia., Design and Measures: We conducted 15 semistructured interviews with 21 members of LHDs, academic institutions, health systems, and community-based organizations involved with health equity strategies or activities in their respective cities. Outcomes included perceptions of the effectiveness of the local health equity plan, participation in other equity-related initiatives, stakeholder engagement, and best practices., Results: We contacted 49 individuals, of whom 2 declined and 21 accepted our interview invitation. Recruitment was stopped after we reached saturation. Thematic analysis identified 5 themes across interviews: (1) organizations were flexible in reallocating resources to address racial and health equity; (2) multidisciplinary teams are necessary for effective development and implementation of health equity plans; (3) community collaboration is required for meaningful and sustainable change; (4) there is a direct relationship between racism, structural inequities, and health outcomes; and (5) health departments have prioritized health equity plan development, but further work is required to address root causes., Conclusions: In the United States, health departments have begun to develop and implement strategic health plans focused on equity. However, the extent to which these plans result in actual initiatives (both internal and external) varied across cities. The current study increases our understanding of how different partners are working to implement structural changes, programs, and policies to reach equity-related goals in our largest urban areas, providing valuable insight for urban health advocates across the country., Competing Interests: No conflicts of interest are reported., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)