Reflections on Philanthropy - Grounded in Science, Built on Partnerships, and Focused on Results
Reflections on Philanthropy - Grounded in Science, Built on Partnerships, and Focused on Results was authored by Healthcare Georgia Foundation president, Gary D. Nelson, for Grantmakers in Health's 2011 annual meeting. View or download the essay.
If we have learned anything from our decade-long philanthropic efforts and investments to improve individual and community health, it is this: Solid science, strong partnerships, and positive results go hand in hand. During Grantmakers In Health’s annual meeting Creating a Healthier Future for Our Kids, Families, and Communities, we at Healthcare Georgia Foundation reflect upon our mission to improve the health of all Georgians and to expand access to affordable quality health care for underserved individuals and communities. During our 10-year pursuit of many seemingly intractable and assuredly wicked problems, a new social contract has evolved with important implications for our direct charitable activities and grantmaking. It is prudent to take the time to examine these effects.
For those of us about the business of improving the health of our children, families, and communi- ties, these are interesting times. Attention to health and health care issues has never been greater, nor so urgently needed in this country. While the national stage is currently focused on who has access to care, the quality of care, and who is going to pay for this care, we know that the more robust discussion – the depth and breadth of issues affecting the health of individuals and families – should be happening at the community level.
Yet Georgia, like many states, too often has faltered in efforts to measurably improve the health of its residents. History shows an unfortunate record of allowing poor health conditions to persist long after problems have been identified and solutions developed. We witness firsthand the effects of declining resources, the absence of leadership, public complacency, and the spiraling costs of poor health outcomes. In Georgia, as in the rest of the nation, political ideology without the benefit of civil discourse pervades today’s health policy. Meanwhile, Georgia continues to rank at or near the bottom among all states on numerous measures of health status. To create a healthier future, we can and must do better!
Healthcare Georgia Foundation stridently pursues this goal through efforts that are grounded in science, built on partnerships, and focused on results. As a learning organization committed to continuous improvement, we share the following five lessons in the hope that others might learn from our successes, as well as our occasional missteps.
LESSON ONE: Listening to Communities – Why We Do What We Do
William J. Foege, former director of the Centers for Disease Control and Prevention and a foremost leader in public health, suggests that if we are to be successful in our work of improving health it is because “in everything we do, behind everything we say, as the basis for every decision we make, we are willing to see the faces.”
Like many of our philanthropic colleagues, we are a statewide foundation with a commitment to understanding, working with, and improving our communities. We aim to actively engage residents, health care providers, nonprofit organizations, and others in cooperative efforts to improve individual and community health. We have sought out not only the faces, but also the voices of those on the frontline of community health.
As such, we each have stories to share about the communities in which we’ve focused our efforts – stories that tell of despair and hope, isolation and connectedness, daunting challenges, and heartfelt victories. The stories have become the “means testing” for our grantmaking. Since its inception, the foundation routinely canvasses Georgians for their insights and opinions through three distinct strategies:
- Listening tours. The foundation has commissioned four statewide listening tours during the past 10 years, each consisting of half-day convenings in multiple communities. Herein, we seek input from and listen to the voices of health providers, consumers, residents, policymakers, elected officials, and other concerned parties. These facilitated discussions help identify health issues that are uniquely place based as defined by geography, population, or provider setting.
- Public opinion polling. Two or three times each year, the foundation conducts statewide polls of registered voters to gauge public opinion on a host of health policy issues. These polls are a valuable means of understanding the perceived roles of individual residents, communities, and government in the structure, delivery, and financing of health care. The polls have been instrumental in the design and evaluation of foundation-funded and foundation-directed health advocacy campaigns, including one initiative to establish a statewide trauma system and another to advance public health in Georgia.
- Statewide convenings and capacity building. One of our most effective methods of promoting partnerships and collaboration has been through the foundation’s biannual statewide conferences for grantees, partner organizations, and other nonprofit health organizations. Since 2002 the foun- dation has convened four, two-day capacity building/networking conferences, reaching approximately 250 organizations per event. To date, the foundation-hosted conference is the only venue in Georgia providing an opportunity for multiple sectors – hospitals, safety net providers, public health professionals, community activists, advocates, academicians, and others – to connect, communi- cate, and collaborate. Initially the need for, and benefits of, this convening were underestimated by both the foundation and its grantees. Over time, however, all parties have come to look forward to and appreciate the conference as a way to progress toward a healthier future for all Georgians.
In summary, the purpose of these important strategies has been to discern the most significant barriers to healthy communities, the assets each community has to make improvements, and the tools and resources each community needs to move forward. The results of four listening tours, plus eight public opinion polls, plus four statewide conferences add up to one profound lesson. As Dr. Foege suggests, these strategies enable us not only to see the faces, but also to hear the voices of Georgia’s diverse communities.
LESSON TWO: Formulating Priorities – How Taking Pulse and Temperature Can Halt the Futile Dollar Chase and Truly Advance Knowledge
Margaret J. Wheatley, president of the Berkana Institute, a global charitable leadership foundation, tells us, “There is no power for change greater than a community discovering what it cares about.” The same is true of our foundation. Over time, we have become increasingly aware of the importance of focusing limited resources on battles, which are winnable – or, at the very least, able to advance the cause. Too often in the past, the foundation and its partner organizations (including our grantees) have been driven by less than rigorous methods of setting priorities. We now believe the greatest opportunities to improve health and health care for underserved populations (that is, the most likely battles to be won) occur when we have aligned our resources with three critical pieces of evidence, which help shape our priorities:
Evidence of Need + Evidence of Demand + Evidence of Effectiveness = Priorities
With this formula in mind, we can remain focused on initiatives aimed at creating healthier futures for our children, families, and communities. Let’s take a closer look at the equation.
- Evidence of Need. The problems can be multitudinous, the burdens to communities overwhelming. Consider just a few: the epidemiology behind morbidity, mortality, disability, and the costs of bad health outcomes. As expected, our funding priorities, as well as the priorities of the communities we support, are strongly rooted in existing data systems that reflect changes in demographics, morbidity, mortality, disability, health care delivery, risk factors, health expenditures, and other factors. Most, if not all, of our grant recipients to date have mastered the skills of documenting and defining need. These definitions can be drawn relative to the past, to the performance of others, or to conditions elsewhere. Need can also be defined by examining current status relative to a standard of acceptability. Evidence of need is necessary in applying philanthropy to healthier futures; in our judgment, however, need alone is insufficient to warrant the allocation of philanthropic resources. There is more to the equation.
- Evidence of Demand. Public declarations that a problem needs attention, that something must be done, that doing nothing is no longer an option all help to create a climate of public urgency – a demand to address an unmet need. Focus groups, public opinion polls, exit interviews, and listening tours all promote greater public awareness and acceptance of an issue as a priority. So do health champions who become the face and/or voice for a particular health issue. Consider the Susan G. Komen for the Cure or the Michael J. Fox Foundation for Parkinson’s Research. Grassroots organiza- tions like Mothers Against Drunk Driving can bring a health issue to the fore, as can the authoritative voice of the U.S. Surgeon General riveting our attention to any number of public health matters. Foundations are uniquely positioned to capture and communicate both the “evidence of need” and “evidence of demand,” particularly when advancing policy agendas.
- Evidence of Effectiveness. Promising practices, if not best practices, exist for many specific health issues that have been the focus of our grantmaking. Ironically, we often find insufficient attention to, or inadequate adoption of, evidence-based programs in the ensuing feeding frenzy to address an urgent issue and/or capture available funding. This was plainly evident in the flurry of funding available to address childhood obesity. As a foundation, we have learned that we can play a key role in program quality assurance by applying the knowledge we have gained to determine potential program effectiveness. Lastly, we continue to be puzzled by the number of nonprofit health organizations unprepared to present a case statement and funding request driven by documented accomplishments or a solid performance record.
To summarize, we now advance the view, both within the foundation and among our grantees and organiza- tional partners, that all three elements of evidence – need, demand, and effectiveness – must exist in order to constitute a priority that warrants the allocation of charitable resources. In doing so, we are more likely to avoid the undisciplined and untested magic bullets, those funding requests that frequently come to us in forms that promise little benefit to our communities, which want and deserve more.
LESSON THREE: Managing Threats to Success – How to Stem the Epidemic of Demonstration Boutiques and Program Tombstones
John Gardner, the noted educator, said, “We are all faced with a series of great opportunities brilliantly disguised as insoluble problems.” We are at a time and in a place in which accountability, trans- parency, and effectiveness frequently trump need. Decisions regarding the allocation of scarce resources are more likely to follow the path of an organization’s performance, accomplishments, and contributions versus the ability to document a need. Setting aside the issue of attribution, we seek to determine what success looks like, what level of evidence we are willing to accept, our tolerance for risk and failure, the level of engagement (time and resources) of all parties, capacity requirements, and our foundation contributions.
In creating healthier kids, families, and communities, we have discovered the benefits of being skilled at recognizing and preventing three significant threats to success.
- Theory Failure. This is best described as the inability to accurately diagnose the cause of, or solution to, a problem. Although considerable attention has been given to the use of logic models to explain the linkage between inputs and outcomes, we as a foundation continue to be at risk of funding so-called interventions that address symptoms only, of supporting programs that presume to be immune to changes in their environment, and of embracing programs based more on notoriety than impact.
- Implementation Failure. This is the inability to carry out a program as it was intended. It is often associated with the phrase if only...as in, if only the evidence-based programs we support reflected sufficient intensity and duration to achieve the desired result. As a consequence of the wide variations in program delivery among the organizations we fund, the foundation has had to become better at diagnosing and monitoring program quality from the start.
- Measurement Failure. Simply defined, this is the inability to accurately measure the effects of a program. It is unfortunate indeed when errors in evaluation limit our ability to detect true results. Failure to negotiate success, define outcomes of interest, and apply measurement methods in a rigorous way leaves us with little more than politely smiling faces, a handful of anecdotes, and many unspoken questions such as: Are we truly confident in what these results are telling us?
LESSON FOUR: Making Change through Policy
Policy and advocacy represent the most promising approaches for a small, statewide foundation like ours to take in creating a healthier future for kids, families, and communities. Whether the topic is health reform, pandemic flu, access to affordable prescription drugs, disparities in health care quality, or the obesity epidemic, these issues take center stage for policymakers, health care providers, and health care consumers. A philanthropic investment in health policy formation and change helps create the conditions for direct, sustainable investments in health and health care.
The foundation’s approach to health policy, adopted in June 2003, emerged from our board of directors’ commitment to leverage its resources to advance the health of all Georgians. These leaders also recognized that changes in health policy were needed to support systems and programs that will have a sustained, long-term, positive effect on the health of underserved individuals and communities throughout Georgia.
As such, foundation leadership identified seven areas in which the foundation would invest in build- ing health policy capacity:
- Nonpartisan research
- Targeted dissemination of results
- Training and capacity building for nonprofits
- Nonpartisan tracking and analysis of health legislation and regulations
- Fiscal policy analysis
- Public education
The foundation has chosen to build health policy capacity in Georgia by working through existing organizations and by promoting the incubation of new organizations, which are not necessarily exclusively devoted to health but include a focus on health policy as part of their mission. Rather than establishing a new, full-service, nonprofit health policy institute – a move that would require substantial and continuing financial support – the foundation instead chose this alternative strategy for two reasons: 1) to stimulate innovative health policy research and build capacity across academic institutions and nonprofit organizations throughout Georgia, and 2) to promote added investments in health policy research and advocacy from other Georgia funders and national foundations. In this way, as the primary funding source for health policy activities in Georgia, the foundation has been able to stretch our resources by engaging other funders and organizations with broader missions in addressing health and health care needs.
An effective health policy strategy must be timely and nimble, and able to take advantage of often narrow windows to influence the policy process. An effective strategy also will adapt to changing needs, an evolving political environment, and emerging opportunities for the foundation to use its influence and grantmaking to be an effective catalyst for better health and health care for all Georgians. Finally, we must acknowledge the inherent risks associated with policy and advocacy strategies, particularly in those instances when the foundation steps out front on the issue.
Lasting solutions to our state’s most pressing health challenges will require a wide array of strategies, most notably informed health policy. We realize that major policy changes are rarely the result of a single individual, organization, or grant. The successes we have attained thus far in areas related to trauma, childhood obesity, and advancing public health have occurred because of the organizational capacity of those we fund and their uniquely collaborative approach to public policy advocacy. That said, our policy successes thus far also have been met with some concern by those opposed to our agenda. In advocating for healthier futures for our children, families, and communities, the foundation has learned that while we may not please all of the people all of the time, we will inform them.
LESSON FIVE: Respecting Community Ethos – Ethics and the Potential Collision of Charitable Principles
Foundation efforts to promote and protect the health of populations frequently bring to the surface ethical conflicts, requiring a special skill set to navigate a complex maze of individual values, neighborhood cultures, and community ethos. As we steer this course, we bear in mind four ethical principles, as well as their potential for conflicts, and we ask ourselves many hard questions.
- Autonomy. As commonly understood today, autonomy is the capacity for self-determination and the acknowledgment of a person’s right to make choices and take action based on his or her own values and belief system. As Henry David Thoreau once remarked, “There is a fine line between care and concern for the well-being of others and respect for persons as people of their own choosing and creators of their own destinies.” As a statewide foundation seeking to achieve measurable improvements in the health status of the population, we frequently find that the policy options most likely to attain desired results are at odds with personal choice. Through grantmaking and/or direct charitable activities, we frequently assume the role of change agent. Many times, we take on that role in situations wherein the individual, family, or community’s freedom to choose is at odds with the science of the improvements we are proposing. So if an individual’s choice endangers himself or herself, puts the public’s health at risk, potentially harms others, or requires scarce or limited resources, are we as grantmakers prepared to make decisions that affect or restrict the individual’s autonomy?
- Paternalism. In support of community priorities, to what extent do we allow funding to interfere with a person’s freedom for his or her own good? In other words, through the programs and policies we promote, are we in essence making decisions for others on the grounds that funders know best? Although the question and the opportunity are not new, the current climate dominated by political ideology seems to have created an environment where even seemingly innocuous health policies (think seatbelts, tobacco use, immunizations, and accessible prenatal care) have hostile overtones. As grantmakers who respect people and accept them as they are, can we assume an effective, paternalistic role by helping them become even better than they are?
- Beneficence/Nonmaleficence. We believe in the principle of conferring benefits and, at the same time, in its corollary of doing no harm (nonmaleficence). It is said that those in health care hurt far more people through errors of omission. The things we don’t do can cause great harm – for exam- ple, the vaccines not given, the science not shared, the limiting of services and support to people because they live in “have not” communities. Whether an act of omission or commission, how does what we do or don’t do in the name of priorities affect our effectiveness as change agents and public health advocates?
- Distributive Justice. This term refers to what society, or any larger group, owes its individual members in proportion to: 1) the individual’s needs and contributions to the group, 2) the resources available, and 3) the organization’s responsibility to the common good. Designed to address unequal access, treatment, and outcomes, our mission-related grantmaking seeks to nullify the adverse effects of programs, policies, and practices that create further distance between the haves and have nots. For us, the first step is addressing the indifference to the health impact of programs and policies. As The California Endowment asserts, “The inequities are unacceptable, but the opportunities for change are undeniable.”
Who will stand up, even if alone, and address issues of social injustice and inequality and elect to navigate through political landmines, all in the pursuit of better health outcomes for individuals and communities? Communities today are required to face tough decisions about the delivery of goods and services, the application of research, and the allocation of resources, wherein the fundamental issues of autonomy, justice, paternalism, and beneficence are on the line. As a foundation, we must be sensitive to, and respectful of, the community ethos and the underlying ethical conflicts that arise from our work.
The Journey Continues
In our efforts to improve health and health care for children, families, and communities, our grantmaking has supported organizations that drive positive change; promote programs and policies that improve individual and population health; and connect people, programs, and resources across the state. We believe the road to better health for all will be paved by efforts that are grounded in science, built on partnerships, and focused on results. On some paths, we have faltered; on others, we have succeeded. Throughout, we have held firmly to our commitment to be a learning organization seeking to achieve greater accountability and transparency. We look forward to the next leg of the journey toward a healthier future for all Georgians.
“There is a fine line between care and concern for the well-being of others and respect for persons as people of their own choosing and creators of their own destinies.”
– Henry David Thoreau
Nelson, G., Reflections on Philanthropy grounded in science, built on partnerships, and foucused on results, Grantmaking in Health, March, 2011.