Becoming Strategic: Finding Leverage Over the Social and Economic Determinants of Health

Douglas Easterling

Laura McDuffee

Foundations increasingly are investing their resources in changing social conditions and are adopting a strategic orientation in order to achieve outcomes. A number of authors have pointed out shortcomings in the way in which foundations design, implement and adapt their strategies. This article provides guidance on how to design an effective strategy, focusing specifically on the task of charting a strategic pathway.

We present findings from a study of 33 health conversion foundations across the United States that are focusing on social and economic determinants of health.  The methodology included semi-structured interviews with foundation leaders (48 total) and an analysis of programmatic materials available on the foundations’ websites.  The interviews revealed the strategic thinking that led to the decision to focus on social determinants of health, as well as the development of specific strategies.  We found that these foundations are operating through a multitude of strategic pathways to achieve improvements in education, parenting, early childhood development, economic well-being, community development, housing, transportation, community safety. These pathways fell into four major categories: 1) expanding and improving relevant services, 2) creating more effective systems; 3) changing policy; and 4) encouraging more equitable power structures.

Some strategic pathways involve incremental improvements in services and systems, while others involve more radical disruptions in how institutions operate and how society is structured.  In the final sections of the article we consider the question of how a foundation can develop a strategic pathway that fits with its mission, values, philosophy, resources and sphere of influence.

Prodding New Thinking and New Action: The Crucial Power of Foundations

Douglas Easterling

Sabina Gesell

With the COVID-19 pandemic, the abrupt breakdown of the global economy and a string of racist killings that brought longstanding inequities into plain view, 2020 will be remembered as the year that we were all called to do more than we previously imagined ourselves doing.

This is certainly true for health foundations. It is no longer sufficient to be a “good grantmaker.” More and more foundations are grappling with philanthropy’s defining question: “What will we do to make the world a better place, especially for people who have historically been denied the opportunity to lead full, healthy lives?”

Over the past two decades an increasing number of health foundations have embraced the role of change agent. And rather than relying on grantees to make change happen, they are intervening themselves to change policy, systems, and institutions (Easterling and McDuffee 2018)…

The Yin and Yang of Equity-Centered Philanthropy

Douglas Easterling

Laura McDuffee

Sabina Gesell

January 2023

Foundations face two competing imperatives when they commit to advancing equity. On the one hand, they are counseled to support and follow the lead of community-based groups that are on the front lines of social change. On the other hand, they are also being challenged to use their power and influence to act boldly to change inequitable structures, policies, and institutions. These two orientations, yin and yang, can take a foundation in different directions and thus cause confusion and internal conflict.

The challenge for a foundation is to balance and integrate the two orientations into a comprehensive and effective approach to advancing equity. Drawing on the experience of six foundations that have embraced equity, we provide guidance on how to manage the yin–yang polarity. These foundations recognize that they have different spheres of influence than do action-oriented groups on the front lines of change, and thus adopt strategies that complement those of their grantees.

One of the most important and challenging aspects of centering equity in philanthropy involves the foundation’s relationships with the groups it funds, especially community- based groups and groups that are led by people of color. We argue that foundation staff need to bring both a yin and a yang orientation when engaging with grantees. Strong working partnerships with open, honest, give-and-take conversations allow for reciprocal learning and collective strategizing, which in turn sets the stage for innovative, breakthrough solutions.

How Can Foundations Promote Impactful Collaboration? 

Douglas Easterling

Laura McDuffee

Funders are increasingly looking to inter-agency and cross-sector collaboration as a strategy to solve complex large-scale issues. Getting to large-scale impact requires the group to successfully navigate a series of challenging tasks involving relationship-building, aligning around a shared purpose, and developing and sustaining effective strategies. Many collaborative groups fail to generate an impact with their work. Funders are at least partially responsible, for example by pre-specifying the problem to be solved or by limiting the group’s ability to adjust its strategy once an implementation grant has been awarded.

Some foundations have developed approaches that significantly enhance the quality of collaborative problem-solving. The Health Foundation of Central Massachusetts built a number of innovative design features into the Synergy Initiative, including: allowing community-based groups to come together to define the problem they want to solve, supporting groups for at least five years, tailoring resources to the different stages of strategy development and implementation, continually emphasizing “getting to outcomes,” requiring groups to rely on evidence, providing funding to hire an evaluation consultant and having the funder directly engaged in the collaborative process, especially in promoting sustainability.

This article presents systems-change outcomes from 14 collaborative groups supported under the Synergy Initiative since 2000. Interviewees with representatives from four of the more successful projects reinforce the value of the Synergy Initiative model in helping groups design, implement, refine and sustain impactful strategies…

The Cultivation Approach to Place-Based Philanthropy: Evaluation Findings from the Clinton Foundation’s Community Health Transformation Initiative

Douglas Easterling

Sabina Gesell

Laura McDuffee

Whitney Davis

Tanha Patel

Cultivation is a decentralized approach to place-based philanthropy where the foundation seeks to activate local stakeholders and assist them in translating their ideas into action. Rather than convening a strategic planning process, cultivation presumes that the seeds of high-payoff solutions are already circulating somewhere in the community. The foundation’s role is to support local stakeholders in developing and implementing their own ideas in ways that produce meaningful impacts.

This article describes the cultivation approaches taken by the Clinton Foundation, Kate B. Reynolds Charitable Trust, and The Colorado Health Foundation, and presents findings from an evaluation of the Clinton Foundation’s Community Health Transformation model.

Building on the results of this evaluation and our experience with all three foundations, we assess the potential of the cultivation approach and indicate how it complements collective impact.

We also introduce a taxonomy of the six roles foundations play in place-based philanthropy, which is useful in clarifying intent and theory of change…

Using Evaluation to Guide Foundations on Community Development 

Douglas Easterling
August 13, 2019

I’m Doug Easterling, Ph.D, a faculty member at Wake Forest School of Medicine. For the past 27 years I’ve been immersed in and fascinated by the work that foundations do to promote community-building and community-based problem-solving. I was the Director of Research and Evaluation at The Colorado Trust when the foundation experimented with approaches like the Colorado Healthy Communities Initiative and have served as an external evaluator or strategy advisor to a dozen foundations doing community-based initiatives.

The more I see and hear, the more that I am struck by the power that foundations have to disrupt the systems, practices, relationships, norms and assumptions that define communities. Disruption is sometimes a good thing – when it causes people to recognize new possibilities, take initiative, reach out to people who are “different,” find common ground, make institutions more inclusive, etc. But too often foundations disrupt communities in ways that foster struggles over for scarce resources, instill mistrust, and undermine residents’ ability to control their own destiny.

Understanding the career pathways of scholars participating in Scholar Programs and Academy

Tanha Patel, Sabina Gesell, Doug Easterling

March 2019

OBJECTIVES/SPECIFIC AIMS: The Wake Forest Clinical and Translational Science Institute (CTSI) put in place a KL2 program in 2007 and introduced an 18-month Translational Research Academy (TRA) in 2010. The TRA provides education and leadership development training, research support services, mentoring, and networking opportunities to 15-20 early-career clinical and translational researchers, including those receiving KL2 awards. The KL2 and TRA programs make up the Mentored-Career Development Core that is administered by the Wake Forest CTSA Education Program. Over the years, the program administrators have collected feedback from the graduates on what they liked and did not like about the programs. However, a comprehensive evaluation to understand the impact of the trainings on helping scholars advance their research and their research careers was not conducted. The purpose of this evaluation was to assess if and how the KL2 and TRA programs are helping scholars advance their research and career in research…

Evaluation of Mentor Academy using self-assessed research mentoring competencies

Tanha Patel, Whitney Davis, Doug Easterling

March 2019

OBJECTIVES/SPECIFIC AIMS: The goal of the Wake Forest Clinical and Translational Science Institute (WF CTSI) Mentor Academy is to contribute to increasing the next generation of faculty with competencies specific to research mentoring. The curriculum of the Mentor Academy is adapted from an evidence-based national curriculum developed by the National Research Mentoring Network and includes 20 contact hours of didactic and experiential training, complemented with outside readings and assignments. A pre-post-follow-up competency assessment is built in as part of the curriculum for both participants and their current mentees. The purpose of this study was to assess self-rated research mentoring competencies among the Mentor Academy participants to better understand the effectiveness of the Mentor Academy…

Cultivating Promising Ideas To Improve Community Health

Douglas Easterling, Sabina Gesell
February 6, 2019

As foundations have moved to more proactive strategies, many are taking the lead in convening interagency coalitions and supporting these groups in developing collective strategies to address complex community issues…

Stakeholder Health: Insights from New Systems of Health

Editors: Teresa F. Cutts and James R. Cochrane

Philanthropy, Health Systems and Community Health Improvement

Douglas Easterling, Allen Smart, Laura McDuffee

The Stakeholder Health movement calls for hospitals and health care systems to re-imagine their role in advancing health. Rather than diagnosing and treating patients one at a time, healthcare organizations are being challenged to intervene in ways that maintain and improve the health of entire populations. This chapter describes how foundations can be brought into the work of Stakeholder Health, especially in ways that go beyond providing financial support for projects and programs. Foundations have shown that they have the means and the skills to convene actors from throughout a community, to publicize issues with institutional leaders and the broader public, to advocate for policies and other systems-level remedies, to inject innovative ideas into the development of community-health strategies, and to build the capacity of the people and the organizations that need to be engaged in the work. Hospitals have much to gain and to learn through partnering with foundations. On the flip side, foundations can come closer to their goals by forging stronger and more strategic alliances with hospitals, something that many foundations have been reluctant to do.

Reconciling Community-Based Versus Evidenced-Based Philanthropy: A Case Study of the Colorado Trust’s Early Initiatives

Douglas Easterling

Deborah Main

One of the dominant tensions in philanthropy involves the question of whether foundations should focus their grantmaking on projects that come from the community versus projects that have a base of scientific evidence. How a foundation answers this question leads to different strategic orientations.

This article describes how this tension was expressed and resolved during The Colorado Trust’s early years of initiative-based grantmaking. The community-based philosophy is illustrated through the Colorado Healthy Communities Initiative, while Home Visitation 2000 serves as an exemplar of the evidence-based approach. The Colorado School Health Education Initiative purposefully integrated the two philosophies.

The community-based and evidence-based philosophies each have inherent limitations which can be overcome by incorporating the opposing philosophy. This finding is consistent with Barry Johnson’s (1992) Polarity Management model and potentially at odds with the principle of strategic alignment.

Methods guiding stakeholder engagement in planning a pragmatic study on changing stroke systems of care

Sabina Gesell, et al

Background: The Comprehensive Post-Acute Stroke Services (COMPASS) Study is one of the first large pragmatic randomized-controlled clinical trials using comparative effectiveness research methods, funded by the Patient-Centered Outcomes Research Institute. In the COMPASS Study, we compare the effectiveness of a patient-centered, transitional care intervention versus usual care for stroke patients discharged home from acute care. Outcomes include stroke patient post-discharge functional status and caregiver strain 90 days after discharge, and hospital readmissions. A central tenet of Patient-Centered Outcomes Research Institute-funded research is stakeholder engagement throughout the research process. However, evidence on how to successfully implement a pragmatic trial that changes systems of care in combination with robust stakeholder engagement is limited. This combination is not without challenges. Methods: We present our approach for broad-based stakeholder engagement in the context of a pragmatic trial with the participation of patients, caregivers, community stakeholders, including the North Carolina Stroke Care Collaborative hospital network, and policy makers. To maximize stakeholder engagement throughout the COMPASS Study, we employed a conceptual model with the following components: (1) Patient and Other Stakeholder Identification and Selection; (2) Patient and Other Stakeholder Involvement Across the Spectrum of Research Activities; (3) Dedicated Resources for Patient and Other Stakeholder Involvement; (4) Support for Patient and Other Stakeholder Engagement Through Organizational Processes; (5) Communication with Patients and Other Stakeholders; (6) Transparent Involvement Processes; (7) Tracking of Engagement; and (8) Evaluation of Engagement. Conclusion: In this paper, we describe how each component of the model is being implemented and how this approach addresses existing gaps in the literature on strategies for engaging stakeholders in meaningful and useful ways when conducting pragmatic trials.

What Do Foundations Have In Mind With The Phrase “Social Determinants of Health”?

Douglas Easterling

Laura McDuffee

An ever-increasing body of research demonstrates that factors such as income, employment, housing, education, neighborhood conditions, political power, and social standing exert a powerful impact on a person’s health status and life expectancy. The County Health Rankings model developed by the University of Wisconsin attributes 40 percent of the variation in health outcomes to social and economic factors, which is twice as high as the contribution from clinical care…

Social Determinants Of Health: How Are Health Conversion Foundations Using Their Resources To Create Change?

Douglas Easterling

Laura McDuffee

Health foundations throughout the United States are expanding the scope of their grant making and initiatives to focus on the social determinants of health (SDOH). They seek to impact a broad range of social and economic conditions, including housing, transportation, education, child care, job training, and economic development, that have been shown to influence the health of individuals and communities. Summarizing a large body of research, the County Health Rankings model contends that 40 percent of the variation in health status can be traced to social and economic factors—twice as much as can be attributed to clinical care…