Although The Robert Wood Johnson Foundation Anthology series contains many compelling chapters on the Foundation's initiatives to improve health and health care, perhaps its most valuable contribution is in demystifying the Foundation. It lets outsiders in on what happens behind the walls of our two-story office building in Princeton, N.J., as well as on the collaborative thinking in which we engage with our grantees. Since this is my first Foreword to the Anthology, I would like to help further demystify the Foundation by explaining our new priorities and how we arrived at them.

The Foundation has a rich tradition dating back to 1972—one that is evident from the approaches to grantmaking examined in this year's Anthology:

Our approach of testing strategies that address important health problems is demonstrated by chapters on the Teaching Nursing Home Program (which aimed at improving chronic care by linking nursing homes and nursing schools), the Fighting Back program (which supported community coalitions to fight substance abuse), Join Together and the Community Anti-Drug Coalitions of America (two organizations that provide assistance to community anti-substance abuse coalitions), and our efforts to contain rising health care costs.

Our approach of educating health professionals and those in a position to affect policy is shown by chapters on the Foundation's Clinical Scholars Program®  (a post-residency fellowship that offers physicians training in social sciences, public health, and health policy), the National Health Policy Forum for members and staffs of Congress and the executive branch of the federal government, and an array of programs designed to attract minorities to the health professions.

Our approach of helping the most vulnerable segments of our society can be seen in chapters on the Foundation's injury prevention programs (which strive to reduce injuries to children living in poor inner-city neighborhoods) and the Homeless Prenatal Program (which provides information and services to homeless pregnant women and women recently released from jail).

Our approach of looking for innovative ideas that can improve health and health care is evident from the Foundation's response to September 11th, and our response to public health emergencies more generally.

As the Foundation's new president and chief executive officer, I wanted to draw on the strengths of our traditional approaches while working with the staff and the board to hone them, and to develop new ways to meet the health and health care challenges of today and tomorrow. Shortly after I took office, I asked members of the staff to think about developing a limited number of specific, measurable objectives for the Foundation. After considering the matter and consulting with outside experts, staff members circulated their ideas and discussed them at an all-day meeting. I then met with the Foundation's senior staff to consider all the ideas on the table and to determine which to select. The priorities were presented to, and adopted by, the trustees in January 2003.

Out of this intensive analytical process came a modest but important refinement of the Foundation's goals and a new set of priorities. The new goals remained basically the same as the old, but with more emphasis on the importance of providing high-quality care. As modified, the current goals of the Foundation are:

  • To assure that all Americans have access to quality health care at a reasonable cost.
  • To improve the quality of care and support for people with chronic health conditions.
  • To promote healthy communities and lifestyles.
  • To reduce the personal, social, and economic harm caused by substance abuse—tobacco, alcohol and illicit drugs.
  • To meet these goals, we have developed an approach we call our "impact framework." It allocates our grantmaking across four "portfolios," much like those of a mutual fund complex that has different portfolios appealing to the varying objectives of individual investors.

The first of these is our Targeted Portfolio, which is designed to address systemic problems in health and health care. Although recognizing that the problems we have chosen to address are complex and multifactorial, the Foundation will—through a combination of demonstrations, training, communications, and research—concentrate on discrete parts of problems with potentially measurable outcomes. This will allow us to better judge our impact. This portfolio includes nine focused objectives, four of which are designed to improve health (behavior and conditions that influence people's health status) and five of which are designed to improve health care (medical care and the system that supports it). Each of the targeted objectives has a defined time limit, running from two years in some cases to a decade in others. The targeted objectives that relate to improving health have to do with smoking, public health, obesity, and alcohol and illegal drugs. Those that relate to improving health care have to do with health insurance coverage, quality of care, racial and ethnic disparities, end-of-life care and nursing.

The second is our Human Capital Portfolio. Through this portfolio, we plan to train leaders and to improve the health and health care workforce through programs such as the Clinical Scholars Program, the Health Policy Fellowships Program, and the Investigator Awards in Health Policy Research program.

The third is our services for Vulnerable Populations Portfolio. This portfolio continues and expands upon the Foundation's programs, such as Local Initiative Funding Partners, Faith in Action, and Cash & Counseling, that serve people in need. This portfolio takes a more direct approach by supporting programs that help people immediately and that develop and disseminate effective strategies that can serve those most vulnerable in our society.

The fourth is the new Pioneering Portfolio. Through this portfolio, we will fund innovative, high-risk ideas and approaches that do not fall into any of the categories above.

To implement the new framework, we modified the Foundation's staffing structure slightly. Previously, the Foundation had been organized along the lines of program management teams—groups of between five and 15 staff members from program, communications, research, financial and legal offices—charged with developing and monitoring programs in a specific area. Since the team concept seemed to work for us, we decided to keep it, but to reduce the number of teams in the Targeted Portfolio from 11 to nine, each corresponding to one of the strategic objectives. The three remaining portfolios—human capital, vulnerable populations, and pioneering projects—are staffed similarly. Each has a program management team responsible for developing and monitoring programs.

Thus there is a lot of ferment within the Robert Wood Johnson Foundation: new leadership, new strategic directions, new staffing patterns. With so many changes coming at once, it is important to remember that we build on a very solid programmatic base, and that analysis of our past and current efforts, through the Anthology series and other means, can serve to guide our actions in the future. We are just at the beginning of a process that will, I expect, enhance the work of the Foundation and its grantees to improve the health and health care of all Americans.