Essay: Reflections On The Challenges Of Philanthropy
1998; Project HOPE; Volume: 17; Issue: 4 Linguagem: Inglês
10.1377/hlthaff.17.4.209
ISSN2694-233X
Autores Tópico(s)Healthcare Policy and Management
ResumoGrantWatch Health AffairsVol. 17, No. 4 Essay: Reflections On The Challenges Of PhilanthropySteven A. Schroeder AffiliationsSteve Schroeder, a physician, is president of the Robert Wood Johnson Foundation, located in Princeton, New Jersey. He practices general internal medicine, part time, at the Robert Wood Johnson Medical School in New Jersey, where he is a clinical professor of medicine.PUBLISHED:July/August 1998Free Accesshttps://doi.org/10.1377/hlthaff.17.4.209AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSHealth philanthropyGrantsAccess to careCommunicationsGrant makingSubstance use disorderEducationSystems of careChronic diseaseChildren's health Eight years have passed since I became president of the Robert Wood Johnson Foundation (RWJF)—eight years of tumultuous health system changes for our country and eight years of rapid growth, riding on a strong national economy, for the foundation. These trends have stimulated a wave of institutional self-examination for us: Are we keeping ahead of the changes? Is the foundation making a sufficient impact? How should we respond to the opportunities presented by our growth in assets? Thus, Health Affairs Founding Editor John Iglehart's well-timed request that I look back on my tenure as president offered a chance for parallel personal reflection that I accepted gladly. Brief Description Of The RWJFLocated in Princeton, New Jersey, the foundation was established as a national philanthropy in 1972 from the bequest of the son and nephew of the founders of Johnson and Johnson, General Robert Wood Johnson. Our mission has not changed since it was formulated by the original trustees: “To improve the health and health care of the American people.” The RWJF is one of the five largest grant-making foundations and the only one of its size to focus exclusively on health and health care. Since emerging on the national scene, we have made grants in excess of $2.8 billion, and our asset size has grown from $1.5 billion to almost $7 billion. This means that we will distribute close to $350 million in grants and contracts in 1998. Adjusted for in-flation, our current asset size is $1.9 billion in 1972 dollars, not much changed from the amount of the original bequest. Between 1990 and 1998, however, our inflation-adjusted assets more than doubled. The foundation today focuses on three major goals: “to assure that all Americans have access to basic health care at reasonable cost; to improve the way services are organized and provided to people with chronic health conditions; and to promote health and reduce the personal, social, and economic harm caused by substance abuse—tobacco, alcohol, and illicit drugs.” 1 Over the past few years we have periodically revisited whether these are the appropriate goals to shape our grant making. Each time the answer has been an emphatic “Yes!” But goals have to be translated into action through programs. Let me illustrate this through a few examples. Programs to improve access include expanding health insurance coverage for the un-insured, making it easier for those who need care to receive it, and training health workers to meet the needs of underserved populations. In the chronic care area we have concentrated on helping persons with chronic diseases to function in their own homes; improving care given at the end of life; and promoting integrated care systems for persons with certain medical conditions, such as dementia. In the substance abuse area we have supported community coalitions to counter drug and alcohol abuse; state coalitions to lower smoking rates; a national center to reduce smoking among children and youth; and programs to reduce the amount of binge drinking among college students. Within each of the goal areas we have supported a wide range of policy-relevant research. (This is only a small sample; at any given moment our foundation has more than 2,300 active grantees.)Between 1990 (when I arrived at the RWJF) and today, our growth in staff has significantly lagged behind our growth in grant making. For example, we had 116 full-time employees in 1990, compared with 142 today. Yet our grant making more than doubled during that period. The decision to restrain staff size was deliberate, based on a sense of appropriate workload, the desire to maintain staff collegiality and communication, and a motivation for efficiency. We would not have been able to do our work with a staff this size without the considerable assistance of new communications and information technologies, new systems of work flow, more reliance on external program directors and advisers, external evaluations, and an increasingly sophisticated staff who remain alert for possible new opportunities and for problems in our funded programs. We are also conscious, however, of the missed opportunities that can result from less rigorous surveillance, as well as the difficulty in continuing to restrain staff size in the face of persistent growth.“Workers in philanthropy are indeed privileged to pursue worthy causes, backed by secure and substantial funding.”Grant making in our early years concentrated almost entirely on the “health care” part of our mission, with early grants going to hospitals and health professional schools. We began to address the “health” component in 1991, when we adopted our goal of reducing harm from substance abuse—the most remediable cause of death and disease. A quarter (more than $260 million) of our authorized grant dollars now support programs addressing substance abuse. In addition to the programs described above, the RWJF has been the major funder in establishing five important new institutions active in the substance abuse field: the Partnership for a Drug-Free America; the National Center on Addiction and Substance Abuse (CASA) at Columbia University; Join Together and the Community Anti-Drug Coalitions of America (CADCA) (both providing technical assistance for community coalitions); and the National Center for Tobacco-Free Kids. In addition, we have sponsored major communications efforts, including the public service announcements of the Partnership for a Drug-Free America, a 1997 Home Box Office (HBO) cable television series on addiction, and the recent Bill Moyers Public Broadcasting System (PBS) special, “Close to Home.” We make grants in support of many types of activities to advance our goals. Our largest investment is in service demonstration projects, which account for 44 percent of our currently authorized $1.1 billion in grant support. We also support research and policy analysis (24 percent), education and training (17 percent), communications (11 percent), and evaluations (3 percent). 2 Seldom do we start with a particular type of activity in mind; rather, we begin with a problem and then ask, “What would it take to prevent/solve/alleviate this situation? Can a foundation investment bring about this change?” Most of the national programs that the RWJF supports are developed by staff after consultation with external experts and are multisite. Grantees are selected from among applicants responding to one of the twenty to twenty-five Calls for Proposals—some for new programs, some for recurring ones—that we issue annually. This process, we believe, makes us more accessible as a funder and enables us to assess proposals in relative terms. These national programs are typically directed by small staffs of experts at institutions outside the foundation that are also supported by grant funds. The programs' national advisory committees provide additional counsel in selecting grantees and in other matters during a program's lifetime. (Outside experts also help RWJF staff to review unsolicited proposals.) The final authority for authorization lies with our seventeen-member Board of Trustees. Current trustees come from industry, government, the voluntary sector, health care, research institutions, and philanthropy.Philanthropic ChallengesWorkers in philanthropy are indeed privileged to pursue worthy causes, backed by secure and substantial funding. It can also be exhilarating to consider the many ways that philanthropic dollars—a precious public trust—can be put to good use. That said, let me turn to some of the principal challenges we face.ACCOUNTABILITY. By law, a private foundation such as the RWJF need only disburse 5 percent of its net assets annually for charitable purposes. Each private foundation is accountable to a governing board and is required to make public only the barest details of its operations and grants. The security of its endowment shields it from the market pressures that drive businesses. Private foundations also are not subjected to the statutory and regulatory constraints, intense public scrutiny, and constituency lobbying faced by government, and the difficulty of measuring the impact of philanthropy blunts the kinds of competitive pressures encountered by academic institutions. No U.S. News and World Report listing of foundations, comparable to its ranking of universities and graduate schools, exists. Whereas students care deeply which medical, law, or business school they are accepted to, grantees probably care little about which foundation supports them, although they care deeply about the amount, duration, and terms of support. In the absence of real competition or rigorous measures of effectiveness, how can a foundation assure itself and the public that it is fulfilling its mission? Ultimately, of course, a foundation's performance is the responsibility of its board. At the RWJF we inform our board and staff, as well as the public, about performance through two principal means: evaluation/feedback and public disclosure.Evaluation. Evaluation has long been integral to our grant-making style. We generally support independent evaluations of our national multisite programs, as well as of large single-site projects. Sometimes the evaluations are formal, involve extensive data collection and control groups, and focus on the extent to which specified outcomes were achieved. The evaluators publish their results in the peer-reviewed literature. Occasionally they show that the program was a “success,” but often they describe shortcomings. Other evaluations are less formal and rely more on the reasoned conclusions of experts in the field. They help to modify existing programs or shape new versions of previous ones. Evaluations of our many training programs fit this qualitative pattern. 3Two examples of how evaluations have changed our programs come from the Clinical Scholars and Faith in Action Programs. In 1992 physician Jack Rowe and economist Rashi Fein evaluated the Robert Wood Johnson Clinical Scholars Program, a longstanding and prestigious program that provides training in nonclinical disciplines such as epidemiology, biostatistics, economics, and experimental design for young physicians who have just completed their residencies. Rowe and Fein felt that the program was very strong and worth preserving but that the RWJF should consider changing the mix of institutions involved, to provide more geographic diversity and to include new settings. Rowe and Fein noted that the program had important institutional impact, in addition to success in its primary training mission. The resultant reorganization led to the defunding of two sites and the creation of three new ones—two in the Midwest.An evaluation of Faith in Action—a national program with 1,100 sites, whose volunteers coordinate interfaith caregiving for homebound persons with major disabilities—encouraged us to expand the program and to consider different designs and funding levels, work that is now under development.Feedback.In addition to formal evaluations, the RWJF avails itself of periodic feedback on its operations. For example, we regularly commission third-party, anonymous surveys of successful and unsuccessful applicants as well as current and former grantees that probe about responsiveness, tone, specific procedures, and clarity of communications. We read the results of these surveys with great interest but are troubled that they do not always reflect some of the complaints we hear in private conversations. We also know that applicants are reluctant to criticize philanthropy, even when promised confidentiality.“We are relentlessly eclectic in our approaches and will support any strategy that has promise.”We also periodically survey the intended audience of our research and policy analysis grants to test whether they perceive these projects as useful and rigorous. We measure the extent to which the research funded finds its way into key journals. We track the careers of the many graduates of our fellowship programs to see whether they are consonant with the programs' purposes. Finally, we track the nation's progress toward health goals that are RWJF priorities; for example, we monitor smoking prevalence among children and rates of health insurance coverage. Since many other factors affect such trends, it is not easy to assess our own impact.Disclosure. We also believe strongly in disclosure, both for accountability and as a means of increasing our impact. As the largest health philanthropy, we have a responsibility to go far beyond minimal efforts to let the public know what we do. We want others to learn from our grantees' experiences. In addition to publishing an annual report, we publish a quarterly newsletter ( ADVANCES ) and various occasional reports, maintain an active Web site, and in 1997 began publishing an annual anthology of findings and lessons from a wide variety of funded programs, which is written for the most part by outside experts. 4 We intend to make this anthology a candid assessment of lessons learned, rather than just a description of who was funded and why. Just this year we began to include on our Web site short summaries of the results of closed national programs as well as of many of the closed single-site projects we fund. 5 This public exposure of our grant-making strategies and results is an innovation for us and, we believe, for the field. Finally, we have long required that major research projects make public-use data tapes, which, stripped of any individual identification information, can be used by other researchers. The tapes can be accessed through the Inter-University Consortium for Political and Social Research. 6IMPACT.Linked to the challenge of accountability is the quest to use philanthropic resources effectively. Because it is so difficult to construct a performance bottom line, how can we distinguish effective from ordinary philanthropy? I believe that philanthropy is most effective when it is highly focused on specific aims, avoids duplicating the efforts of others, and is versatile and pragmatic in its methods while steadfast in its goals—a formula more easily stated than practiced.At the RWJF we debate, both internally and with outside consultants, such questions as: What are the best strategies to advance goals such as improving the functioning of persons with chronic illnesses? Should we attempt to highlight the problem, support research on the most promising methods, publicize best practices, train future leaders, track and disseminate promising practices from the field, or some mixture of all of the above? If we select a mixture, what is the optimal blend of grant types? What is the right dollar amount for each component and each individual project within these components? Because the answers to these questions are never empirical or absolute, philanthropy will always be more an art than a science.Another tension is between rigor and relevance. Because complex social problems such as drug abuse, elder-care problems, or teenage pregnancy rarely result from one cause, single-shot therapies are seldom effective. Yet, if successful, a broadside of interventions often leaves us without a clear understanding of what accounted for the success. If a program does not produce immediate results, proponents can always argue that longer or more intensive efforts were required, or that the program set in motion a series of forces that ultimately will produce the desired result. Because changing individual or community behavior depends on so many variables, there is seldom agreement on either cause or effect. We have seen this recently with three societal trends: the rise in teenage smoking and thedeclines in teenage pregnancies and in homicides. Many plausible hypotheses have been offered for each, but precise causal linkages probably cannot be established. In my view, this does not argue for pursuing only what can be precisely measured, but it does argue for humility in interpreting behavioral trends and in assessing the impact of philanthropic programs.SOCIAL CHALLENGES.In addition to the challenges of accountability and impact, working in philanthropy can mean encountering some difficult dilemmas that underlie attempts to improve the human condition. Chief among these in the United States are issues of race and class and the proper role of government.Race and class.Race and class are important because lack of health insurance, poor access to decent medical care, and poor health status are much more prevalent among the poor and certain racial minorities, especially African Americans. Because the roots of these conditions are complex and intertwined, approaches to improvement are rarely simple. For example, difficulties in agreeing on leadership and suspicion of “mainstream” organizations often surface in some communities. Despite the progress of the civil rights era, deep racial divisions still persist. It is not easy to develop the kinds of open, trusting relationships that are needed to bolster community-based health improvement projects. Equally difficult is the challenge of entering into frank dialogue about the role of race in America. In contrast to race, class differences are seldom acknowledged in this “egalitarian” country. Yet abundant scientific literature documents that class is perhaps the most important determinant of health. 7 Put simply, those with higher incomes and more education live longer and healthier lives. This relationship holds across the entire income and educational spectrum. That is, the wealthy do better than the upper middle class, and those with graduate education live longer than those whose education stopped at college. The reasons for income-related health disparities are complex and not fully understood. In part they relate to class differences in such behaviors as smoking, heavy drinking, use of illegal drugs, diet, personal hygiene, and exercise. In part they stem from variations in access to high-quality medical care. Other factors surely are involved, such as the degree of social support available or the amount of perceived independence at work. As a health philanthropy, we have concentrated our grants on behavioral and health care factors that might improve health status. We realize that one reason that U.S. health status lags behind that of other developed countries is our huge income disparities. Yet remedying income or educational disparities is obviously beyond the RWJF's reach. Role of government. The role of government is an issue about which many persons have strong and often opposing views. Indeed, I am often asked whether the RWJF favors government or private solutions to social problems. My answer is “neither.” We are relentlessly eclectic in our approaches and will support any strategy that has promise. That said, the federal government does pay for about 47 percent of the trillion-dollar health care industry and strongly influences the remainder through its tax policies, its oversight of employer-based retirement and health benefits plans, and its public health programs. 8 In addition, state and local governments play a major health and health care role through their Medicaid programs, health insurance regulation, environmental health programs, and administration of public hospitals and various health care and public health agencies. Any philanthropy interested in improving health and health care must be cognizant of the roles of government and sensitive to opportunities to inform public decisionmakers. The RWJF has responded to this government presence in four major ways. First, we have contributed extensively to data collection and policy analyses to help inform the public debate. Second, we have supported model service demonstration programs with the hope that government will adopt successful ones. Examples of this strategy working for the RWJF are early support of emergency medical response systems, including 911 access; integration of hospital and out-of-hospital acquired immuno-deficiency syndrome (AIDS) health care services; school-based health clinics; and health care services for homeless persons. Third, we have invested in the training of future leaders, some of whom have gone on to become surgeons general; direct the Centers for Disease Control and Prevention (CDC) or the Agency for Health Care Policy and Research (AHCPR); lead local, county, or state health departments; or direct academic health centers. Fourth, we have long worked with state governments wrestling with responsibilities that have been increasingly “devolved” to them, such as enrolling uninsured children in Medicaid or a state variant or incorporating persons with chronic diseases into Medicaid managed care programs.“We speak through our grantees and do not seek a high institutional profile.”Given the perceived decline of the federal government as a funder of new social programs, we must look to work more with the private sector, where the dominating market forces add new sets of complexities. Throughout our history the RWJF has supported innovative private-sector organizations seeking to improve health and health care. The National Committee for Quality Assurance (NCQA); On Lok, an integrated community-based program for the homebound elderly; and the Society of General Internal Medicine are just a few such organizations that received early funding and then grew to be successful. We continue to value initiatives based on voluntary action.INTERNAL MANAGEMENT.Before working in philanthropy, I had leadership responsibilities in academic medicine and in managed care. Some management challenges are universal: setting strategic missions and goals; recruitment, retention, and advancement of staff; budgeting and financial management; information flow and data systems; communications; and monitoring progress. In some ways, however, foundation management differs from management in business, government, or not-for-profit voluntary agencies.On my desk is a framed quotation from John Kenneth Galbraith, sent by a colleague when he heard of my impending move to philanthropy: “Nothing so gives the illusion of intelligence as personal association with large sums of money.” The downsides of the RWJF's possessing a secure endowment are that it can breed arrogance, insularity, and complacency. Indeed, all three of those charges are regularly directed at philanthropy, and I had heard them all—and even voiced them a time or two myself—before entering the field. Most foundations, including ours, inevitably disappoint most of our customers, since our acceptance rate for unsolicited proposals is less than 10 percent.To counter these traits, we strive to recruit staff strongly attracted to the foundation's mission and driven by a service ethos. Because foundation officers are less apt to hear customers' criticisms than are workers in other fields, we must search hard for them—for example, by conducting surveys—and have staff willing to respond to them when they occur. An institutional value system helps to ensure performance that is goal driven and in keeping with the best philanthropic practices.Core commitments.Over the past year we have tried to articulate more explicitly to the RWJF staff the foundation's core commitments and values. With the caveats that what follows is a work in progress and that our institution is still relatively young, here is how we currently view our core commitments:“Our first core commitment is to the American people. We will do this by being faithful to our mission of improving their health and health care. We should never forget that our fundamental purpose is to improve the lives of Americans, by both encouraging healthier living and the conditions that promote health, as well as by promoting positive changes in the way health care is delivered.“Our second core commitment is to our constituents who help us fulfill our mission, as well as to the fields in which we work. As a grantmaking organization, we act through our grantees. We have the responsibility to be open to the ideas of others, to select grantees in a manner that is fair as well as effective, to be courteous and prompt in responding to applicants, and to be clear about how we monitor our grantees' progress. We should do everything within our power to assure the success of our grantees and should respect their commitment to their work and to the institutions they represent. In addition, as the nation's largest private foundation in health, we have a special responsibility to ensure the vitality of the fields of health, health care, and philanthropy. This entails training future leaders, assuring the integrity of vital national data, and educating the public.“Our third core commitment is to our staff. Staff at all levels of the organization must meet the highest possible standards. Thus, we need to recruit the best possible talent, emphasize staff development, and prepare selected staff members for leadership positions in other organizations. Staff at all levels should be treated with respect and dignity, work in a supportive environment, and be held accountable for their work using fair performance standards.”Core values.I recognize that these commitments are only fine-sounding words unless we back them up with our daily actions. Thus, certain core values should characterize our foundation's work:(1) “We pursue goals that are important to the health of the American public. By keeping our focus on the health of the entire population, we emphasize issues that are more germane to vulnerable subgroups—such as access to health care—but also address problems that affect everyone, such as substance abuse. We must cast a broad net for potential grantees, seeking them in all sectors of the American landscape—public and private—and explore many ideas.“Fidelity to this value also requires that we give unfettered access to the knowledge gained from our grants to all those who might use it. Focusing on openness shapes the way we operate grant programs, the content of our publications and outreach, and our commitment to help our grantees communicate their experiences and findings.”(2) “We speak through our grantees and do not seek a high institutional profile. We have chosen to work primarily through our grantees, rather than establish ourselves as a primary source of information. This value is reflected in our initiatives to build grantees' communications capacity, in our creation of such institutions as the National Center for Tobacco-Free Kids and the Center for Studying Health System Change, and in our support of young professionals—a strategy that is relatively expensive and has a long incubation period.”(3) “We seek to employ and develop a staff that is distinguished by its professionalism and competence. We seek bright, motivated, highly ethical individuals who care passionately about our mission. We work them hard, help them to develop, and value them highly even after they leave. We see them as change agents while they are with us and later in their subsequent employment, and we strive to maximize their growth and potential.”I wish that the act of establishing core commitments and values would be sufficient to prevent arrogance, insularity, complacency, and the other ailments to which philanthropies and other organizations are susceptible. But it is just a first step. For any philanthropy to achieve its full potential, it must continuously examine its role, performance, and results and develop action plans that will move it forward. We spend a lot of time thinking about this, and we are aware that we can do better.Final ThoughtsThat foundations occupy a unique role in America stems from two circumstances: First, in our economy individuals can amass great wealth, which then can become the well-spring of private foundations. Second, in contrast with other developed countries, in the United States the governmental role in providing social services and supporting cultural activities is more limited, thus creating more opportunities for voluntary associations and charities, as well as philanthropy.The philanthropic sector is not monolithic. Philanthropies today span a wide range, according to their sources of wealth, size, governance, mission, thematic interests, geographic focus, type of grant making, and operating style and culture. In today's climate of increased distrust of institutions, philanthropies—including ours—are undergoing more scrutiny and criticism. Although this is not always pleasant, it is healthy. Along with the privilege of working in philanthropy should come the obligation of greater public accountability and disclosure.Since entering the world of philanthropy I have found an impressive commitment to the craft of grant making here among my colleagues at the Robert Wood Johnson Foundation and elsewhere. They are drawn to the field by the opportunity, as one Iowa philanthropist said, to “leave it better than you found it.” There may not be consensus about the intent or the strategies that different philanthropies use, but there is no doubt in my mind that they are united in their devotion to improving the human condition. The ultimate challenge, of course, is how to accomplish that.NOTES1. The Robert Wood Johnson Foundation Annual Report, 1997 ( Princeton, N.J. : RWJF , 1998 ). Google Scholar 2. Schroeder S.A. and Knickman J.R. , “Views from the Funding Agencies: The Robert Wood Johnson Foundation,” Medical Care ( May 1998 ): 621 – 624 ; and Go to the article, Google Scholar Isaacs S.L. , Sandy L.G. , and Schroeder S.A. , “Grants to Shape the Health Care Workforce: The Robert Wood Johnson Foundation Experience,” Health Affairs ( Summer 1996 ): 279 – 295 . Go to the article, Google Scholar 3. Isaacs et al. ., “Grants to Shape the Health Care Workforce.” Google Scholar 4. Isaacs S.L. and Knickman J.R. , To Improve Health and Health Care, 1997: The Robert Wood Johnson Foundation Anthology ( San Francisco : Jossey-Bass , 1997 ). Google Scholar 5. The Robert Wood Johnson Foundation's Web site is at www.rwjf.org . Google Scholar 6. For further information, call the consortium at 734-763-5010 or visit www.icpsr.umich.edu ; data sets are also listed on the RWJF Web site . Google Scholar 7. Wilkinson R.G. , Unhealthy Societies: The Afflictions of Inequality ( London and New York : Routledge , 1986 ); and Crossref, Google Scholar Marmot M.G. , Kogevinas M. , and Elston M.A. , “Social/Economic Status and Disease,” in Annual Review of Public Health ( Palo Alto, Calif. : Annual Reviews , 1987 ), 111 – 135 . Crossref, Google Scholar 8. Levit K.R. et al. ., “National Health Spending Trends in 1996,” Health Affairs ( January/February 1998 ): 35 – 51 . Go to the article, Google Scholar Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article MetricsCitations: Crossref 1 History Published online 1 July 1998 InformationCopyright © by Project HOPE: The People-to-People Health Foundation, Inc.PDF downloadCited byCommunity-Based Organizations in the Millennium: Opportunities for Growth, Challenges to Survival22 October 2009
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