The Local Initiative Funding Partners Program

A challenge for philanthropy is balancing two opposing approaches to grant making. The first emphasizes multipronged efforts at solving a problem through focused and coordinated portfolios of grants. This more centralized approach usually requires a high degree of involvement by a foundation's staff in the design of programs. The second approach is to listen to the field and respond to ideas that flow from potential grantees. This approach encourages local solutions to local problems.

The Robert Wood Johnson Foundation primarily follows the more centralized approach, at least in its national programs. However, even when the Foundation determines the area that it plans to fund, it seeks to incorporate locally generated ideas by inviting local agencies to send ideas for projects they think are important.

The Local Initiative Funding Partners Program falls squarely in the camp of bottom-up grant making. It is a collaborative effort between local foundations and The Robert Wood Johnson Foundation where both partners fund worthy projects developed at the local level.

As Irene Wielawski, a former investigative reporter for the Los Angeles Times and current evaluator of the Foundation-funded Reach Out program, reveals in this chapter, the story of Local Initiative is a convoluted one with many ups, downs, and curves. What began with an attitude of noblesse oblige was gradually transformed into a series of philanthropic collaborations among equal partners. It is an example of grant making where it took much effort and many years to get it right.

The history of the Local Initiative Funding Partners Program offers lessons for philanthropy about the importance of local ownership and control of programs, developing open lines of communications among partners with sometimes differing agendas, and establishing equality in relations among people working for large national foundations and smaller local philanthropies.

There is no part of Interstate 64 leading southeast from Charleston into the "hollers" of West Virginia's coal country that can seriously be described as a straight stretch. The four-lane highway swoops and twists through the hilly terrain, revealing every now and then a cluster of houses and small stores tucked into a valley. These are the hamlets of eastern West Virginia, isolated from one another by the steep hills, by tradition, and by hard times.

For some local children, the first day at Collins Middle School in Oak Hill is also the first real venture out of their holler. The school covers grades 5 through 8, and draws youngsters from tiny elementary schools scattered over a three-hundred-square-mile area. Some ride the bus for more than an hour each way.

Vicki Lagos, the only guidance counselor at Collins Middle School and all-purpose confidant for many of the children, says the adjustment process can be harrowing. Besides the homesick ones who wind up crying in her office or visiting the school nurse with anxiety-related stomach aches, she sees children whose deteriorating schoolwork and behavior reflect the stresses of poverty and turmoil at home. The once coal-rich towns have been largely mined out, and alternative employment consists mostly of minimum-wage service jobs. At Collins Middle School, the region's precipitous economic decline shows up this way: 77 percent of the students today qualify for the federally subsidized lunch program, up from 32 percent only ten years ago. Of the 817 students at Collins, about 12 percent fit the federal definition of homeless, most of them boarding with relatives or friends. Single-parent homes are more common than they were a generation ago, school officials report, and alcohol abuse is a factor in the home life of a significant number of students.

All of which helps to explain the school administration's enthusiasm for the newest member of their professional staff: Hamlet Smith, mental health counselor. He began coming last year to meet with children Lagos referred to him for disruptive classroom behavior, school phobias, depression over family upheaval, and other troubles that can set a child on a downward spiral of school failure. The results so far are promising: student absenteeism has declined significantly in the two years since counseling became available, as has the number of students suspended from school for fighting or other serious misbehavior.

"In this area, there are many children who would not get any service-- health or mental health--if it wasn't provided at the school," says David Perry, the principal at Collins. "We're trying to keep the children on track, get them ready to achieve in high school. This [the counseling service] is making a difference."

How mental health counseling came to be available at Collins Middle School is the story of an innovative undertaking by The Robert Wood Johnson Foundation to help improve health care in local communities. It is also the tale of how a major national foundation learned humbling lessons about what it takes to work productively at the community level.

The program responsible for Hamlet Smith's presence at Collins Middle School is called the Local Initiative Funding Partners Program. It was born twelve years ago of the belief that those closest to the problems of local health care systems might also come up with the best solutions, inspired by a knowledge of their communities that no national foundation, academic center, or beltway think tank could match. These solutions, by virtue of being homegrown, might also have more staying power than those imposed by outside entities. At the same time, local efforts could be enhanced by the expertise and technical know-how available through partnership with a large national foundation.

Today, the program comes as close to realizing those guiding principals as it ever has. From a tentative beginning in 1987, Local Initiative has evolved into one of the Foundation's core programs, and has been reauthorized four times by the trustees. A total of 150 awards have been made over the life of the program, involving collaborations with more than a thousand local cofunders and public agencies. Local Initiative operates as a dollar-for-dollar matching grant program, and, as of 1999, the Foundation had authorized it to distribute $7 million annually in four-year grants of up to $500,000. Potential grantees can seek matching funds from local sources, including foundations, charitable organizations, corporations, and public agencies.

What distinguishes Local Initiative from other large-scale matching grant programs is the degree to which responsibility for the idea, the project design, and the execution rests with the community. Local Initiative gives money with relatively few strings attached compared to other Foundation programs and those of most national philanthropies. The main eligibility requirement is that the proposed project fit into one of the Foundation's three funding categories--ensuring that all Americans have access to basic health care, improving services to people with chronic illness and disability, and reducing the harm to people and communities caused by abuse of tobacco, alcohol, and illicit drugs. Beyond that, applicants compete on their merits for matching grants; the ratio of applicants to grant winners is about 15 to 1.

The program's unusual hands-off approach has resulted in an eclectic mix of health improvement projects, each bearing a distinctly local flavor. In West Virginia, the idea of putting mental health services in schools flowed directly from the region's difficult topography and economy. Project leaders wanted to locate the services in a place that parents would trust and that children could get to via the region's only reliable public transportation: school buses. Contrast this with the Local Initiative project in Surprise, Arizona, which works in reverse by exporting primary care services from institutional settings to rural areas where farmers and migrant workers live and work.

There is variety in mission, as well. In Winthrop, Maine, Local Initiative helps pay for community nurses who counsel residents on healthy lifestyles and guide them to appropriate preventive health services. In Boston, Local Initiative supports an innovative drug court that gives substance-abusing lawbreakers a treatment alternative to prison. In Indiana's Amish community, it finances a project to improve pediatric dental care and dental hygiene awareness. And, in a strategic corner of the popular Kahuku Farmer's Market on the island of Oahu, it helps make possible a diabetes screening project for at-risk Hawaiians.

The breadth of Local Initiative and the abundance of funding partners today suggest a rosier reception in local philanthropic circles than the Foundation's idea initially met. The program has gone through periods of painful reassessment and unexpected conflict with local funders. It was even briefly canceled by the Foundation because of internal controversy over its scope and structure. Indeed, if one were to chart the progress of Local Initiative from concept to true community collaboration, the picture would look very much like a roadmap of West Virginia's mountain country--no straight stretches, and a lot of ups and downs between the curves.

If any one person can be credited with getting Local Initiative off the ground, it is Terrance Keenan. Today Keenan enjoys wide recognition as an innovator in philanthropy. He joined The Robert Wood Johnson Foundation as a vice president in 1972, when it became a national philanthropy, and, though he retired in 1990, he continues to work three to four days a week as a special program consultant.

Both Keenan and the nascent Robert Wood Johnson Foundation were far less prominent when Keenan set out in the late 1970s to try to sell the earliest version of what would become the Local Initiative Program. His task was to get local philanthropies to fund projects in their own communities that the Foundation had identified as worthy. But the idea of a new foundation in Princeton, New Jersey, telling local philanthropists how to spend money on their home turf, did not go over very well. Keenan vividly remembers a trip to Texas, in which he called on foundations from one end of the state to the other trying to get them interested in financing a start-up health clinic in an abandoned church in San Antonio. A doctor, several nurse groups, and some nuns were organizing the effort, but they had no contacts in any of the local philanthropies. Keenan essentially acted as their ambassador.

"The Robert Wood Johnson Foundation was not that well known at the time, and we were not necessarily liked," he recalls. "I remember getting reamed out by the head of one medical society foundation. He said, among other things, that he didn't like Yankees."

Those early missteps have come to be known as Stage 1 of Local Initiative's conceptual evolution. The projects for which the Foundation was trying to drum up financial support were all primary care health centers, not the diverse array of health improvement efforts that characterize the program today. But even with such straightforward candidates for funding, the Foundation was having little success in forging the philanthropic partnerships it had envisioned. On the contrary, resentment among potential partners was building, fueled by the perceived arrogance of the Foundation.

"I realized it would be easier to get a favorable reception if I had some money to put on the table," Keenan says. So emerged the idea of matching grants to augment whatever local support a project was able to garner. This financial commitment by the Foundation was first tested in the 1980s in a precursor program to Local Initiative called the Community Funding Partners Program. It also paved the way for Stage 2 in Local Initiative's development, in which the responsibility for selecting projects that deserved support was relinquished by the Foundation to the community's own philanthropic organizations.

With these philosophical cornerstones--local control of the idea and a dollar-for-dollar matching commitment from the Foundation--Local Initiative was formally launched in 1987. Matching grants worth $8 million were authorized over two years, though only sixteen projects would actually be funded during this period, for a total of $4.2 million. Because the projects were generated entirely by the local philanthropies, the Local Initiative Program quickly became one of the most diverse in the Foundation's portfolio. It stood out as a radical departure from the status quo, and discomfort within the staff was palpable. Local Initiative's predecessor, the Community Care Funding Partners Program, had given grants only for the development of school-based clinics and primary care centers. Although a third of Local Initiative's first grants fell within that framework, others dealt with controversial issues such as child sexual abuse, pregnancy among rural teens, and HIV infection in street children. Local Initiative came to be viewed as a minifoundation unto itself, and some staff members believed that its guidelines and oversight were inadequate. These tensions coincided with a general scale-back in grants by the Foundation. The upshot: funding for Local Initiative was suspended in 1989, at the conclusion of its second round of grants.

In 1990, the Foundation's current president, Steven A. Schroeder, began his tenure. One of his first tasks was to streamline the Foundation's funding priorities. Ten categories of philanthropic activity were pared to the three that rule Foundation grant making today.

Local Initiative's advocates within the Foundation saw an opportunity in the new structure to address internal staff concerns and give Local Initiative a second chance. In an October 24, 1990 memorandum to Schroeder summarizing the program's origins and demise, several ameliorating proposals were outlined. Local Initiative could use the Foundation's newly defined priorities to guide its own funding decisions. Matching grants could be limited to projects that reflect overall Foundation priorities.

But problems in Local Initiative's external relationships also needed to be addressed. Some local partners had complained about the program's application process, saying it made them feel more like supplicants than partners. Once again, the Foundation found itself in the position of alienating some of the very people with whom it had hoped to build long-lasting, productive partnerships.

There was nothing disingenuous about the Foundation's commitment to locally conceived and funded health improvement projects. These intentions had consistently been made plain in both external and internal communications. "The program is intended to foster innovations to problems in health that are generated by community people and institutions themselves, and not by an external funding agency as is the case with most matching grants programs," said a 1989 internal report. "A basic premise of the Program is that community and local ownership regarding the idea behind the project--combined with local funding--are factors that are likely to strengthen the chances for the project to take hold on a long-term basis."

The subtleties of making these intentions real, however, continued to be a challenge. Yes, the Foundation had come a long way since the days when Keenan was dispatched to trade its ideas for someone else's cash. But Local Initiative remained uncharted territory for a national foundation that had risen quickly to prominence. One observer, describing the Foundation's image at the time, called it "the 800-pound gorilla of health care philanthropy." It had fallen into a somewhat autocratic style of doing business with those seeking grant support, and that style was undermining the egalitarian message of Local Initiative.

The part of the application process that had raised hackles in Local Initiative's first partnerships was a requirement that community-based funders put money into a project with no guarantee of a Foundation match. Essentially, the Foundation reserved an escape for itself. Local funders had no such out, even though they were putting up an equal amount of money. Qualifying for the Foundation match translated for some into months of effort, including personal and public advocacy. When more than one local funder was involved--and some Local Initiative projects have had as many as twenty--things were dicier still. If the Foundation rejected a project at an advanced stage of development, potential partners on the home front would be left with a lot of explaining to do.

"Local funders live with their mistakes. Johnson can walk away from them," explains Robert Eckardt, of the Cleveland Foundation in Ohio, a partner in several Local Initiative projects.

George Penick, currently president of the Foundation For The Mid South in Mississippi and a member of Local Initiative's national advisory committee, speaks from personal experience when he describes the consequences of rejection as "extreme." In the late 1980s, Penick was executive director of the Florida-based Jessie Ball duPont Fund when he applied for a Local Initiative grant. The project involved sending medical residents to underserved rural areas to provide maternal and child health care. One partner in the effort was a major university that would be responsible for supervision and training of the residents. The duPont Fund, at Penick's urging, authorized the requisite up-front money, totaling several hundred thousand dollars. Confidence was high as the proposal reached the finalist ranks for a Local Initiative grant, and subsequently passed an on-site review by the Foundation. But then the Foundation declined to match, and the project had to be scrapped.

"It was embarrassing in the community, and very difficult for me personally," Penick recalls. "Here I'd been telling my trustees that The Robert Wood Johnson Foundation was a good partner."

His trustees were irked enough to direct Penick to write the Foundation a letter. "It had an edge," he recalls. "I basically told them this was no way to treat local partners and build trust."

Requiring up-front money bred exactly what Local Initiative had sought to minimize: power imbalance. The design flaw was potentially fatal to the Foundation's goal of genuine partnership with communities. In the October 1990 memorandum to Schroeder arguing for a relaunch of Local Initiative, program staff acknowledged that this procedural problem, among others, needed fixing. The memorandum and proposals for corrective action were persuasive. Local Initiative was reauthorized by the Foundation trustees in July 1991 and has operated without interruption since.

The new and improved Local Initiative--Stage 3 in the evolution--requires applicants only to demonstrate an intention to fund up to a certain dollar amount, contingent upon receiving a matching commitment from the Foundation. A face-saving two-stage application process also was introduced, thereby sparing those rejected in the first round (the majority of applicants) the work of developing a full proposal. In response to staff suggestions, the program is now restricted to projects that reflect the Found ation's three funding priorities. Finally, like most other national programs funded by the Foundation, the program has been physically moved out of the Foundation, and a national program office, located at the Health Research and Education Trust of New Jersey in Princeton, New Jersey, has been established to emphasize the independence of Local Initiative and the equality of the partnerships under its auspices. The national program director is Pauline Seitz, a former program officer at the Foundation who worked on Local Initiative in its early years.

For local health improvement projects, the prospect of doubling their financial resources through partnership with a national foundation is compelling--mesmerizing, even. It can make the difference between a small-scale demonstration project and one large enough to make a tangible, difference in community life. And in all the process and paperwork that stand between an applicant and a foundation's money, other, less tangible, philanthropic goals can get lost. Yet these other benefits are the heart of th e gamble that is Local Initiative--mining fresh ideas from the field and cofunding programs that can improve health locally and have the potential to be replicated nationally. For the Foundation itself, the investment has been returned many times over in new insights about local health care needs. The danger of intellectual isolation and policy myopia at the Foundation's Princeton headquarters is also lessened by the back and forth with Local Initiative partners.

Local partners similarly describe their alliance with the Foundation as valuable beyond the sum of the check. In interviews, many said that having a prestigious national health care foundation as part of the coalition boosted their projects' credibility with political leaders and others critical to sustaining the effort long term. The presence of an outsider in locally driven efforts also has helped community collaborators overcome divisive rivalries, just as having an out-of-town house guest might subdue discord at the family dinner table. For community philanthropies daunted by the complexities of the health care field, the Foundation's technical expertise is also valued. And, even in cases where the local funder has well-defined goals in mind, the Foundation's emphasis on innovation can tweak the direction of their initiatives into areas they might not have entered on their own

So it was with school-based mental health services in West Virginia. The major funding partner in that project is the Claude Worthington Benedum Foundation, a fifty-five-year-old philanthropy based in Pittsburgh. Two-thirds of Benedum's grants are made in West Virginia. This was a condition set by the foundation's benefactors, Michael Benedum, a successful oil wildcatter, and his wife, Sarah. Both were natives of West Virginia and knew its poverty well. When their only son, Claude, died, they sought to honor him and his birthplace with a lasting legacy. Today, the Benedum Foundation gives $10 million to $15 million annually in grants, on assets of $300 million. This is important money for a poor state like West Virginia, but Benedum is dwarfed by the colossal Robert Wood Johnson Foundation, whose assets total more than $8 billion.

Their bank statements notwithstanding, Benedum feels that it stands on an equal footing with The Robert Wood Johnson Foundation in its Local Initiative partnership. What it lacks in cash, Benedum supplements through its credibility with state policy makers in West Virginia. Over years of philanthropy concentrated in such a small place, it has amassed a sophisticated understanding of community needs in a state where 65 percent of the population lives in towns of fewer than 2,500 people. It also throws a wider net than The Robert Wood Johnson Foundation in the variety of projects it funds.

"Our grants program in West Virginia ranges from education to health and welfare to economic development," says Beverly Walter, Benedum's vice president for programs. "It does give us an opportunity to see the interconnectedness of all these areas, perhaps more than a national foundation dedicated to health issues."

Mental health is one service that Benedum knew was greatly needed, though a low priority for state funding. Several years before, it had collaborated with state health and education officials to establish West Virginia's network of twenty-eight school-based health centers. At the time, Benedum matched state dollars authorized to start the clinics. Today, the school health centers are widely regarded as having improved health care access for youngsters, and have earned their own line item in the state budget.

Tackling the mental health component of children's health services was a logical next step for Benedum. It joined forces with the New River Health Association, a federally qualified health center in Scarbro, West Virginia, that ran several of the school clinics. Meetings with New River staff and officials of the state Bureau for Public Health, the education department, and the department of psychiatry at West Virginia University led to a Local Initiative application. The proposed project would add on-site mental health counseling at four schools, and establish a system of psychiatric consultation at nine school-based health centers.

Craig Robinson, executive director of New River, said the idea actually came from early work in setting up the original school health centers. In surveys of parents, students, and school faculty, the need for services that broadly fell within the mental health realm kept showing up as a community priority.

"I think the teachers and administrators were observing behaviors in the classroom," Robinson says. "They were hungry for additional tools to use rather than just discipline. The parents wanted help with talking about sex and drugs and alcohol. The children identified relationships and family issues. There was no question that mental health was an unmet need of adolescents in the area."

At Collins Middle School, Vicki Lagos, the guidance counselor, was an early advocate of having a mental health counselor in the friendly setting of the already established school clinic, known to the children and parents as the Collins Wellness Center. She'd had nothing but trouble trying to refer children to outside mental health agencies. They were often far away, requiring a child to miss a day of school and parents to miss work. Staff turnover was high, fragmenting the care. Communication with the school was nonexistent.

"It was a disaster," Lagos recalls. "I spent a lot of my time getting all of these agencies coordinated with the school and trying to straighten out the paperwork. They all had different forms." Moreover, if a child missed school and others found out it was for a visit to a mental health agency, he or she could be back at Collins with the cruel label "psycho."

"Telephone, telegraph, and tell-the-other-fella--that's how the communication goes in the towns around here," says Collins' principal, David Perry. Parents as well as children feared the stigma. But with a counselor in a room just off the nurse's office, discretion is easier to maintain. If there is any residual community discomfort, the program that draws its funding from foundations in far off Princeton and Pittsburgh and the state capital in Charleston can rely on it being handled by the most local of Local Initiative's community partners: Vicki Lagos and David Perry.

"We're both graduates of Collins," Lagos points out. "My husband went here, too. So did my parents. There aren't too many people around here that we don't know. If someone's worried, they're probably going to call me up. I tell them, 'I trust the clinic.' That pretty much settles it."

The Local Initiative project in Winthrop, Maine, is built on relationships no less intricate than those that sustain the West Virginia effort, but of a different sort. Here, a traditional philanthropic and public health initiative--improving the overall health status of a community--has been joined by atypical partners: two commercial health insurers, one of the state's largest employers, and the state Medicaid program. The partners involved have put this Local Initiative undertaking at the cutting edge of change in the nation's health care system. In a time of fractious rhetoric, with public health and commercial health care claiming sharply distinct missions and public and private payers playing the blame game, this tiny project has everyone sitting at the same table and embracing a common goal.

That goal is measurable improvement in community health. The program is called Healthy Futures. It essentially reinvents the old-fashioned concept of a town nurse, once common in New England, who was responsible for overseeing the health needs of families in her assigned area. Her duties included well-baby checks and advice to young parents, keeping tabs on elderly or infirm shut-ins, health and nutrition education for school children, immunization, hygiene, disease control, and anything else that came up. Healthy Futures calls its team of community nurses "health advocates." Reflecting a new health care need that has resulted from the complexity of our current systems, the program's health advocates spend a great deal of time helping patients understand how to communicate their health needs and how to obtain timely services.

"We have people who have gotten appropriate services up to a point but don't follow through for some reason," says Paula Cutter, a nurse who runs the program. "Our health advocates visit people in their homes and become a nonthreatening human contact for them. Patients will tell them, 'I can't face calling and finding out the lab results. Will you do that for me?' We're also finding that many people retain only about half of what the doctor tells them. The elderly will be very polite and say, 'Yes, doctor, yes, doctor,' but they are not really understanding. Our health advocates help them with medication instructions and other things that they may have missed during the office visit."

The program also organizes community forums and citizen groups so that the initiative to pursue health improvement becomes truly grassroots, as opposed to something imposed on the population by well-meaning professionals. Out of these forums have come walking groups, dieting support clubs, and other groups that involve people outside the pilot population of a thousand Winthrop residents.

That pilot population comes from the beneficiary rosters of Healthy Futures' partners. They are Healthsource Maine, a managed care plan that is part of the CIGNA Health Care company, Blue Cross and Blue Shield of Maine, Hannaford Bros. Co., a self-insured grocery store chain, and the Maine Medicaid program. Everyone in the pilot group is offered home visits by one of the program's two health advocates. Participation is voluntary.

The challenge of Healthy Futures is not only to improve the health of individual participants but also to sell the goal of community health to its disparate partners. Healthsource, for example, has market-share ambitions in Maine. Managed care covers only about 22 percent of the state's one million residents. Dean Paterson, manager of health education for Healthsource and its liaison with Healthy Futures, says the company's business goal is no less than 100 percent of the health insurance market. Because healthy people are less costly to insure, Paterson says the company has a long-term interest in investing in community health, even if not everyone in Healthy Futures' target population is currently a Healthsource member. Moreover, because Maine has a relatively stable population, and only five insurance plans to chose from, people not covered by Healthsource today might very well be covered tomorrow. Paterson and her company would rather that they came into the plan well informed about diet, exercise, the dangers of smoking, and other health-related behavior.

Peter Hayes, manager of employment benefits for Hannaford Bros.,¹ brings to Healthy Futures a critical view of managed care as it exists in Maine today. He sees the project as an opportunity to test the costs and benefits of managed care in a way that health plans have not. This, Hayes says, is crucial bottom-line information for his company, which is Maine's third-largest employer, after the state and the shipbuilder Bath Iron Works. The chain has 150 grocery stores in nine eastern seaboard states. Of its 24,000 employees, 10,000 receive health insurance benefits through the company. The rest, mostly part-time workers, are ineligible. In Maine, Hannaford Bros. employs 10,000 people, of which about 4,200 receive health insurance benefits.

As a businessman, Hayes is irked by the inadequacy of information available to negotiate the best value for the company's investment in employee health benefits--about $30 million annually. "The grocery business is very competitive. We make about two cents for every dollar of product we sell. So you have to know the cost structure of every product to the fraction of a cent. We don't have any of this information for health care."

Hayes sees managed care as a misnomer in the health insurance industry because the plans really haven't proved their ability to better manage care, beyond offering discounts over earlier fee-for-service models. "It is well known that 30 to 40 percent of our costs are related to lifestyle issues," Hayes says. "So in Healthy Futures we have a chance to try programs and get the data we need to make appropriate changes."

The changes would be in the way purchasers of health services negotiate. The payback from investment in Healthy Futures, Hayes believes, could be significant for his company and others with whom he works in a business group called the Maine Health Management Coalition.

"We are trying to become better purchasers," he explains. "I used to just buy on price. Now I am trying to buy on value. To do that, there has to be a component of patient satisfaction and outcome value.... I don't want to reward the plans for managing the health dollar on a short-term basis but reward them for changing outcomes."

And finally there is the perspective of Francis Finnegan, director of Maine Medicaid. "We have a $1.1 billion Medicaid program that loves to pay for institutional care and severe illness. If someone has a cardiovascular event, follow-up care is lousy," Finnegan complains. "How can we turn it around to focus on health? We think having a community nurse who works on getting the lipid levels down and so on will be a big improvement. It is a low-cost investment for potential large-scale gain. If it works, we would like to take Healthy Futures and expand it statewide."

Like philanthropy in education, the arts, and other areas, health care philanthropy aims for the greatest number of beneficiaries--the project that changes the world. The seed may be planted in a small town, benefiting a relatively small handful of participants. What grows from that seed is the test of the experiment.

The question is, Whose idea has the greatest potential to do that? More often than not, national philanthropies have looked to their well-educated and accomplished staffs to come up with ideas. These generally are laid out in a document known as a request for proposal. The majority of requests for proposals define operational criteria and then invite organizations to propose model projects.

Local Initiative represents the opposite of this top-down approach to grant making. It is a bottom-up, reactive form of program development where the national foundation invites a wide array of ideas from the field. A bottom-up program such as Local Initiative diffuses power, control, and responsibility for the project's outcome into the community and away from the national foundation. In this way, it hopes to stimulate innovative solutions to health care problems of national significance, tailored to local conditions, and to incubate models that have the potential of being replicated elsewhere.

Will professors of public health a generation from now point to Winthrop, Maine, as a model for collaborative behavioral change? Will children of the coal towns of eastern West Virginia prove the case for integrating health services for the mind and body?

Whether local solutions will have a far-reaching impact is unknown today. But some things can be said from an examination of Local Initiative's first decade--and one of them can be said unequivocally: the process of bringing a philanthropic concept from idea to effective implementation is as grueling for a foundation as it is for grantees.

Like community efforts to change health-related behaviors or address unmet health care needs, Local Initiative has had to adjust and readjust to overcome obstacles to its goals. It has had to figure out how to align intentions with actions and learn fr om the people it set out to instruct. And, although it has come a long way from rocky beginnings, there are still elements of the program that irk partners. At a national advisory committee meeting in the fall of 1998, longtime member David Ross of NationsBank in Kansas City objected to the Foundation's continued use of the term "lead partner" to distinguish the biggest local funder in a particular project from the rest.

"They all have egos," Ross noted, arguing that this sort of hierarchical ranking is unnecessary for effective program management, and undermines relationships at the community level. The comment is illustrative of how easily perceptions of power imbalance can be tripped, and the sensitivity required to sustain effective long-term, long-distance partnerships.

Those running Local Initiative today say it is still a work in progress and probably always will be. The lessons, so far, are these:

1. Peter Hayes left Hannaford Bros. in early 1999 to become a health care benefits consultant for J & H Marsh and McLennan in Portland, Maine. However, his successor, Shirley Bloom, says Hannaford's commitment to and interest in Healthy Futures remains as stated. (return to article)