Editors' Introduction: Grantmaking insights from The Robert Wood Johnson Foundation Anthology      By Stephen L. Isaacs and James R. Knickman

Book reviews, letters we've received, and personal comments from readers suggest that the Anthology series provides an understanding of The Robert Wood Johnson Foundation in three ways.

• First, by making public the Foundation's decision-making processes and revealing the thinking of key people involved in programs, the series helps demystify the Foundation and the work of its grantees.
• Second, by providing critical, unbiased analyses of the programs the Foundation has supported-many of them written by award-winning journalists-it provides insights into what has worked, what has not, and why.
• Third, by offering a panorama of the Foundation's investments from 1972 to the present, it enables readers to understand the approaches and the strategies that the Foundation has adopted to improve the health and health care of all Americans.

In last year's Anthology, we offered some insights based on the first three volumes in the Anthology series. In this fourth volume, we expand on that base and identify a number of others. The ten insights on grant making gleaned from The Robert Wood Johnson Foundation Anthology follow below:

1. The Importance of Mission and Basic Values

The mission of The Robert Wood Johnson Foundation, "to improve the health and health care of all Americans," shapes the Foundation's culture, guides its investment strategies, and establishes program limits. It is complemented by four core values: pursuit of goals important to the public's health; reliance on data; speaking through grantees; and employing an expert staff.¹ The mission and the core values give the Foundation both a clear identity and a solid base from which to pursue its more specific goals-increasing access to health services, improving chronic care, and combating substance abuse. They also give the Foundation a stability that allows it, through its programs, to advance ideas that might not be popular at any given time, such as increasing the opportunities for minorities to become health professionals, promoting generalist medicine, and combating addiction to tobacco.

2. Staying Ahead of the Curve

Foundations generally want to stay ahead of the curve-to play a leadership role by supporting innovative ideas that will be adopted by others. But how does a foundation staff member-or anybody, for that matter-know where the curve is, much less how to stay ahead of it? To a great extent, as the Anthology series demonstrates, it is through the efforts of a highly professional staff and expert consultants who identify-"sense" might be a better word-areas that are at the point where Foundation support could make a difference. The Anthology provides many such examples. During the 1970s and 1980s the Foundation invested in emergency medical services, regional perinatal care networks, and training of nurse practitioners and physician assistants. None of these was in the foreground when the Foundation first took action, but interest in them was stirring, and some health professionals were predicting that they were likely to become important to the health of the American public. As it happens, all three areas developed so rapidly that the contribution of The Robert Wood Johnson Foundation cannot easily be distinguished from the changes made outside of its programs. By supporting early efforts in these fields, however, the Foundation helped propel their development and guide them as they grew. A more recent example is the Foundation's work on the issue of the harm caused by tobacco. By the 1980s, the evidence was well-established and the tobacco problem was catching attention. Yet no major foundation was directly engaging the issue. In the early 1990s, The Robert Wood Johnson Foundation began to play a role by funding research, policy analysis, anti-smoking coalitions, and a variety of other programs. Although it is difficult to separate the Foundation's role from the changes that took place in society during the 1990s, the Foundation clearly was ahead of the curve. More recently, the Foundation has turned its attention to addressing unhealthy behaviors and to a new field called "population health," taking advantage of recent data and a sense among many health professionals that these are areas of growing importance.²

3. Shaping Public Debate and Perceptions About Difficult-to-Solve Issues

Even a foundation that provides grants of over $400 million a year can expect to have only a limited impact in a trillion-dollar-plus health economy. Many problems, such as drug addiction and the high number of uninsured families, appear all but intractable. Another insight from the first four volumes of the Anthology series is that despite an apparent powerlessness to bring about immediate and dramatic changes in society, foundations can keep an idea alive, even though it has not gained wide popular acceptance, and can work to influence the way opinion leaders and the broad public perceive issues. Take generalist medicine. Although The Robert Wood Johnson Foundation was swimming against the specialist current for many years, its persistent efforts lent stature to the idea that more generalist physicians were needed, and its grants to medical schools helped them prepare for the influx of students pursuing generalist careers once managed care began creating jobs for primary care physicians. Another example is treatment of people towards the end of their lives. A large research project, called SUPPORT, found that the wishes of dying patients and their families were not being understood by physicians because of difficulties in communication. This disturbing finding led the Foundation to undertake a major multiyear effort to raise the consciousness of the medical profession and the public about the importance of improving the treatment of people towards the end of their lives. The Robert Wood Johnson Foundation also helps shape public attitudes through its research and communications efforts. Much of what the public knows about the uninsured comes from the widespread distribution of findings from a series of Foundation-funded access-to-care surveys beginning back in 1976. Similarly, much of what is known about medical malpractice, managed care, substance abuse, and sexuality derives from the dissemination of research undertaken by Foundation grantees.

4. Changing the Focus of Demonstration Programs

For its first 15 to 20 years, The Robert Wood Johnson Foundation followed a relatively straightforward strategy. It would often fund a demonstration program that tested an innovative service approach or policy idea in a number of locations; if the approach appeared successful, the federal government would likely take it on and expand it substantially. The early reputation of the Foundation was built upon its national demonstration programs, some of which-emergency medical services and nurse-practitioner training are but two examples-were adopted by the federal government. But the federal government no longer picks up and expands many programs, particularly when these programs increase taxes. As a result, The Robert Wood Johnson Foundation has adopted new and more nuanced approaches to demonstration projects:

• Demonstrations now tend to be larger as the Foundation tries to affect the lives of more people through its programs. As Sharon Begley and Ruby Hearn point out in this volume, the Urban Health Initiative is not just a pilot project. It attempts to improve the health and safety of young people across entire cities.
• To a greater extent than before, the Foundation works with state and local governments. Since 1991, for example, it has assisted state governments interested in reforming the financing of health care services. And since 1992, it has supported Making the Grade, a program built on the premise that the long-term financial stability of school-based health services "must be secured through state and community involvement."³
• The Foundation now looks to fund coalitions of nongovernmental organizations. One example is the Faith in Action program in which the Foundation supports coalitions of religious congregations and organizations whose members volunteer their services to help those in need. This approach has proved so promising that the Foundation recently agreed to award more than $100 million over the next seven years to fund 2,000 additional local coalitions.

5. Adopting Multi-Faceted Approaches that Embrace Institutions and Fields

In his chapter for this year's Anthology, Frank Karel observes, "the most powerful way that foundations can spark social change is to use their monies to fund the creation of new institutions or fundamental change of existing institutions." Although foundations are more limited in their ability to do this than in earlier days, The Robert Wood Johnson Foundation has had a rich experience in developing new institutions and transforming existing ones. With this approach-what might be called "360 degree funding"-all the key aspects of an innovation are covered.

For example, to develop and shape the new profession of nurse-practitioner in the 1970s and 1980s, the Foundation funded nurse-practitioner programs in nursing schools willing to add them; a fellowship program for nurses who became the nucleus of trainers of nurse-practitioners; the creation of a professional society for nurse practitioners; research on relevant aspects of nursing; programs that employed nurse-practitioners, and collaborations among institutions (such as universities, HMOs, state agencies, and employers) to train nurse-practitioners.

Similarly, the Foundation has adopted a wide variety of strategies to encourage managed care organizations to improve the diagnosis and treatment of their members with chronic conditions. It has supported the collection and dissemination of information on HMOs and chronic care; brought together researchers and practitioners focusing on the topic; worked with a national accrediting agency to include chronic care among its indicators; funded demonstration projects; and financed research. While it is too soon to know whether managed care will significantly alter its chronic care practices, this array of programs prepares the groundwork for such institutional change.

6. Reforming Systems of Delivering Health Care Services

Another grantmaking insight derives from the Foundation's many years of experience with programs seeking to overcome the fragmentation of health care services and to reorganize the systems that deliver them. There is much to be learned from its successes and its failures.

First, although "systems change" has a neutral ring to it, systems are rooted in politics and people. What is logical organizational reform for one person may be loss of turf and income for another. Reforming delivery systems implies that foundations understand, and become involved-to some degree at least-in the messiness and factionalism of political processes. As Beth Stevens and Lawrence Brown observe in their chapter in the 1997 Anthology, successful interventions require "a systematic reading of the political complexion . . . and close contemplation of the main players in the reform 'game' in terms of the depth of conflicts among their values and interests and the prospects that they might endorse an intervention that they can implement effectively."⁴ Foundations have not generally shown an aptitude for this, and, moreover, legal strictures limit what they can do in the governmental arena.

Beyond ascertaining the politics and the players, systems reforms require an understanding of a complex web of laws and regulations. Attempts to provide a seamless net of health care services for homeless people in the Homeless Families Program foundered, in part, on the number and the complexity of the systems that needed to be reformed. Similarly, a national program to integrate acute and long-term care for older people not only had to shape multiple delivery systems but also to coordinate two distinct and complicated government programs, Medicare and Medicaid. In a classic understatement, Joseph Alper and Rosemary Gibson observe in their chapter for this year's Anthology that "making the financing of acute and long-term care more rational has proven to be challenging."

Although systems change may be important, it should not be viewed as a panacea. Beginning in 1987, the Foundation funded a series of programs to integrate services for people with chronic mental illness. While the programs were able to change the way mental health services were organized and delivered in some communities, improved service delivery did not necessarily lead to improved mental health. Rather, the emphasis on improving delivery systems obscured the importance of improving the quality of the services themselves. In other words, inadequate services were being delivered in a more efficient manner.

7. Investing in People

One consistent insight emerging from the Anthology series is the importance of investing in people in order to bring about long-term improvements in the health care system. From its earliest days, the Foundation has followed a conscious strategy of building the health care field by improving the capacities of those working in it. Since 1972, the Foundation has been supporting the Clinical Scholars Program, which gives physicians committed to academic careers the opportunity to learn about the management, social, computer, and behavioral sciences, and the Health Policy Fellowships Program, which gives mid-career health professionals the opportunity to learn about federal health policy processes by working for a year in a Congressional office. Since the 1980s, its Minority Medical Education Program has been giving qualified minority college students the tools to become better medical school applicants, and its Minority Medical Faculty Development Program has been offering research fellowships and mentoring to promising minority junior medical school faculty members. For more than two decades, the Foundation has supported David Olds, whose research has demonstrated the value of having nurses visit pregnant women in their homes.

Although the notion is difficult to prove, the Foundation's fellowship programs-and others that invest in individuals-are widely considered to be among its successes. They give capable people the wherewithal to take risks and develop their abilities. As Lewis Sandy and Richard Reynolds concluded in their analysis of academic medical centers in last year's Anthology, "Investments in people pay off . . . Supporting bright young people early in their career may be a more effective institutional change strategy than direct institutional grants."⁵ Their conclusion-expanded to include individuals of all ages-has been echoed throughout the Anthology series.

8. Staying in for the Long Run

In its earlier years, the Foundation tended to support programs for a limited number of years and then move on to other endeavors. While this approach had the advantage of allowing the Foundation to get things started and then let others-usually the federal government-take them over, it also had the potential disadvantage of a premature exit. Authors of Anthology chapters have questioned whether the Foundation moved away from nurse practitioners, public health dentistry, and regional perinatal programs too early. While nobody can reasonably expect that a program be continued forever, The Robert Wood Johnson Foundation now takes a longer-term view, in many cases supporting programs for a decade or more. This gives institutions and individuals the chance to reach a level of maturity that they might otherwise not have been able to reach.

9. Maintaining Flexibility

Even with the security given them by longer funding cycles, programs need to adapt to changing circumstances. Market forces have altered the course of many Foundation-funded programs: for example, the Reach Out program to encourage physicians to volunteer their services began just as managed care reduced the free time of doctors, and the Strengthening Hospital Nursing program attempted to increase hospital nurses' responsibilities at a time when managed care was placing their very jobs in jeopardy. Grantees have had to show great ingenuity just to keep programs alive.

The mercurial nature of the health care system affects the Foundation's strategies as well. Take the evolution of its approach to managed care. As Janet Firshein and Lewis Sandy observe later in this Anthology, the Foundation was an early supporter of the nonprofit, staff-driven HMO model that was developing in the 1970s and early 1980s. As a for-profit entrepreneurial model came to dominate managed care in the 1980s and 1990s, the Foundation's approach evolved toward emphasizing quality control in HMOs, encouraging HMOs to provide services for people with chronic illnesses and addictions to tobacco and alcohol, and understanding better the effects of managed care.

10. Respect for Grantees and Ownership of Programs

The tenth and final lesson from the Anthology series is the importance of treating grantees and potential grantees with respect, involving them from the early stages of project development, and encouraging program ownership. In their attempt to discover why some Foundation-supported programs to improve children's health seem to take hold and others do not, Sharon Begley and Ruby Hearn conclude that community ownership is a critical factor. "Without a feeling that a community is guiding a program, there is no public pressure to continue once the Foundation ends its support," they observe. Irene Wielawski noted in last year's Anthology that the Local Initiative Funding Partners Program began as one in which The Robert Wood Johnson Foundation exercised considerable power over local foundations. In response to the dissatisfaction this attitude caused among the local foundations, The Robert Wood Johnson Foundation adopted an approach based on mutually respectful relationships among the partners.⁶

The Robert Wood Johnson Foundation often determines its strategic priorities and program designs after extensive consultations with experts. For national programs, it issues a "call for proposals" to which potential applicants are invited to respond. At the same time, the Foundation often holds workshops and meetings with potential applicants, whose ideas are worked into the process even after a call for proposals has been issued. Programs are carried out by the grantees, usually with monitoring and technical support from a national program office and counsel from a national advisory committee of prominent experts. At its best, this process creates a close and mutually respectful relationship between the Foundation and its grantees; enriches the processes and context where innovative ideas are generated, funded, evolved, and developed; and gives grantees ownership of their programs.

In today's hyper-economy, with philanthropic resources surging and new foundations dotting the landscape, it is more important than ever that grant makers share their experiences and learn from one another. The approaches pursued by The Robert Wood Johnson Foundation offer one window into promoting social change in a complex environment. While all foundations are different and there is not necessarily a right way to practice the craft of philanthropy, we hope the Anthology series is, and will continue to be, a place to look for insights that readers can adapt to their own circumstances.

Notes

1. S. A. Schroeder. "Core Values of The Robert Wood Johnson Foundation." In S. L. Isaacs and J. R. Knickman, (eds.), To Improve Health and Health Care 1998-1999: The Robert Wood Johnson Foundation. San Francisco: Jossey-Bass, 1998. (return to article)

2. See chapter 1 by J. M. McGinnis and S. A. Schroeder in this Anthology. (return to article)

3. P. Brodeur. "School-Based Health Clinics." In S. L. Isaacs and J. R. Knickman (eds.), To Improve Health and Health Care 2000: The Robert Wood Johnson Foundation Anthology. San Francisco: Jossey-Bass, 1999, p. 14. (return to article)

4. B. Stevens and L. Brown, "Expertise Meets Politics: Efforts to Work with States." In S. L. Isaacs and J. R. Knickman (eds.), To Improve Health and Health Care 1997: The Robert Wood Johnson Foundation Anthology. San Francisco: Jossey-Bass, 1997. (return to article)

5. L. Sandy and R. Reynolds. "Influencing Academic Health Centers: The Robert Wood Johnson Foundation Experience." In S. L. Isaacs and J. R. Knickman (eds.), To Improve Health and Health Care 1998-1999: The Robert Wood Johnson Foundation Anthology. San Francisco: Jossey-Bass, 1998. (return to article)

6. I. Wielawski. "The Local Initiative Funding Partners Program." In S. L. Isaacs and J. R. Knickman(eds.), To Improve Health and Health Care 2000: The Robert Wood Johnson Foundation Anthology. San Francisco: Jossey-Bass, 1999. (return to article)