Organized American philanthropy was born with bold and audacious goals. Andrew Carnegie challenged philanthropy to “do real and permanent good in this world.” In a similar vein, John D. Rockefeller wrote that “The best philanthropy…is not what is usually called charity. It is…the investment of effort or time or money…to expand and develop the resources at hand, and to give the opportunity for progress and healthful labor where it did not exist before.” Both of these early philanthropic pioneers emphasized making change — and making change stick.
To accomplish their goals, many foundations develop strategies to address problems with one intervention. For example, in 1972, the Robert Wood Johnson Foundation identified the problem of the lack of good emergency medical care in most American communities. To address this problem, the Foundation gave grants to 44 sites to test the model that we now know as the 911 system. By 1973, Congress passed the Emergency Medical System legislation that had 11 of the 15 components that were in the Foundation’s call for proposals. Looking back, we can say that this effort was very strategic and widely successful.
This approach was typical of the work of many other foundations. In his book, The Foundation, Joel Fleishman describes building schools for African Americans in rural areas, creating the National Bureau of Economic Research, supporting the publication of Gunnar Myrdal’s An American Dilemma, and developing Sesame Street as successful single-intervention efforts. These all had impact, improving people’s lives in varying degrees. They were projects with simple engines of change with few moving parts. They were projects where foundations directly purchased goods.
By contrast, foundations in a few instances have strategically addressed widespread, nasty problems with multiple interventions intended to produce social change. The Green Revolution, ending poverty in the United States, and reducing smoking are examples about which Fleishman wrote. Today, the Ford Foundation is addressing global inequality and the Robert Wood Johnson Foundation, the culture of health.
How do foundations successfully address these kinds of embedded and far-reaching problems through multiple interventions? Over the past several years RWJF enlisted the expertise of independent evaluators to analyze the impact of its work in a few fields in which RWJF has made significant investments over long time periods — tobacco, end of life care, substance use, and chronic illness care.
The Foundation has invested:
- nearly $170 million to improve end of life care between 1988 and 1996;
- about $700 million in efforts to prevent tobacco consumption between 1991 and 2009;
- nearly $700 million to address substance use from 1988 to 2010; and
- about $670 million to address chronic illness care between 1972 and 2010.
The stories of these investments are reported in RWJF’s Retrospective Series. Each of these reports provide valuable insights into the elements that made the Foundation’s grantmaking successful in using multiple interventions to create real, permanent social change.
Commitment over a long period of time is crucial. RWJF’s efforts to address tobacco use, end of life care, chronic illness care, and substance use were all nearly 20 years long. Overall, tobacco and end of life care efforts were the more successful of these. Chronic illness care and substance use had successful programs, but were less successful as social change efforts. Thus, “stick-to-it-ness” is a necessary, but not sufficient condition for success.
Strategy has to be emerging, evolving based on lessons learned. In addressing the issues of tobacco and end of life care, program officers made tactical changes in response to what they learned during these efforts. By contrast, staff involved in the Foundation’s work on chronic illness care and substance abuse never experienced a collective “aha” moment that provided lessons for success.
The Foundation’s work on end of life care, for example, started with the Study to Understand Prognoses and Preferences for Outcomes and Risk of Treatment — referred to as the SUPPORT Study. The second phase of SUPPORT was a random controlled trial with about 2,600 patients using care that involved computer models to predict serious illness and death, specialty-trained nurses to communicate with patients and families, and written instruction about patient and family wishes. Results from the study published in the major medical journals showed that the intervention was a complete failure. It did not improve physician’s knowledge of patient and family wishes. It did not reduce time spent on ventilators. It did not reduce pain. And it did not reduce resource use at the end of life.
It was clear to Foundation staff and many others that improving end of life care would require doing something different — a new multi-interventional approach. To rethink how to address the issue and develop a new approach, the Foundation funded the Institute of Medicine (IOM). The 1997 IOM report provided the Foundation and others with a roadmap for change, which the Foundation used to design its ultimately successful effort in improving end of life care.
Identify and use levers for change. Foundations do not have the resources to buy widespread changes for long periods of time. Building interventions into systems, policies, or the environment allows change to be scaled and to stick. Instead of basing its smoking reduction work solely on counseling or advertising — which would need to be funded forever — RWJF’s and its allies’ work supported the passage of tobacco taxes and clean indoor air laws. The former created disincentives for smoking — especially among the young — and the latter shifted the cultural norms about smoking. Laws scaled the interventions and made them stick.
Creating or supporting institutions that live on after a foundation’s grantmaking efforts end is another way to make change stick. In improving end of life care, the Foundation funded the Center to Advance Palliative Care at Mount Sinai Hospital in New York City to continue work in this area.
Coordinate many interventions to bring about social change. In addition to using leverage to spread interventions and make them stick, foundations have to coordinate many interventions, like a social movement would, to bring about widespread social change. The best example of when coordination of interventions created powerful social change comes from RWJF’s work on tobacco. RWJF developed evidence for its approaches with the Tobacco Policy Research Program and its successor program, which produced significant findings. Through the program, economists researched the role of price on smoking rates, finding that the higher the price, the lower the smoking rate, especially for children. Researchers also showed that clean indoor air laws improved health.
As a second element of its strategy on curbing tobacco use, RWJF funded coalitions of advocates in 42 states through its Smokeless States initiative. These advocates could work on the passage of legislation with funds received from other organizations. The research information generated from RWJF grants provided advocates with their policy agenda, as they focused on the passage of tobacco taxes and clean indoor air laws, as well as providing access to cessation interventions.
The third element of the tobacco strategy was the development of the Center for Tobacco Free Kids — which started with Foundation funding in the fall of 1995 and, as was the case with Smokeless States, received funding from other sources. The Center provided a voice to the tobacco control movement at the national level. Eventually, it was involved in negotiation over the master settlement agreement and the development of legislation to regulate tobacco, and provided strategic communications for the tobacco control movement.
Finally, RWJF invested in cessation efforts, incorporating them into routine practice of medicine by developing guidelines on tobacco cessation for physicians and quality standards for health plans. For example, the American College of Obstetricians and Gynecologists and the U.S. Public Health Service released guidelines that recommended the adoption of an evidence-based approach to cessation.
In this way, RWJF coordinated several different types of interventions to bring about formative change. The Foundation started with research about what policy changes would reduce smoking — tobacco taxes and clean indoor air laws. That information was then fed to communications and advocacy efforts like the Campaign for Tobacco Free Kids and Smokeless States. Those efforts in turn promoted legislative and health system reforms.
One foundation can’t do it alone; it needs collaborators. Private foundations always need grantees as partners. To bring about widespread social change, foundations need additional collaborators. In its tobacco work, RWJF had more than 20 additional collaborators, including the American Cancer Society and Americans for Nonsmokers’ Rights. And foundations need to be flexible in the roles they will play in social change: sometimes that role is being the lead; sometimes it is leading from behind; and other times it is providing the glue that holds efforts together.
Bringing about real and permanent social change is difficult. Foundations need to operate in a different fashion when they wish to attack nasty, widespread problems.
David C. Colby was the vice president for policy at the Robert Wood Johnson Foundation in 2014, and the vice president for research and evaluation from 2007-2014. Follow him on Twitter at @davidccolby. He thanks Amy Woodrum for her reactions to an earlier version of this post.
