With assets of approximately $8 billion, The Robert Wood Johnson Foundation is the nation’s fifth-largest foundation. To carry out its simple but daunting mission of improving the health and health care of all Americans, the Foundation strives to foster innovation, develop ideas, disseminate information, and enable a wide range of committed people to devote their energies to improving the nation’s health and well-being. While the Foundation’s primary mechanism for effecting change in health and health care systems, practice, and policy is its awarding of approximately $400 million of grants each year, the Foundation also energizes the health field by convening experts, by creating synergy among its grantees and partners, and by disseminating knowledge about key issues in health and health care through its Web site, the Web sites of key grantees, and a range of publications produced by its staff in Princeton and by its grantees.

The Robert Wood Johnson Foundation is committed to a set of principles that guide both its grantmaking and its internal operations. It focuses on improving the health and health care of the most vulnerable individuals in our society; it is inclusive and nonpartisan in its strategies; it addresses significant and challenging problems and continues working on them long enough to have an impact; and it values the passion, commitment, and energy of both its grantees and its staff.

The Foundation structures it staff and grantmaking activities around four portfolios:

The initial five chapters in this year’s Robert Wood Johnson Foundation Anthology look at the Foundation’s national programs aimed at improving health.

Every year, the Anthology features one chapter putting a small local program under the microscope. This is one way to give a human face to the Foundation’s activities and to illustrate that not all of its grantmaking involves large programs designed to affect nationwide change in policy or practice.

One goal of the Anthology is to demystify the world of philanthropy, at least insofar as philanthropy is practiced by the Robert Wood Johnson Foundation. This year’s Anthology contains two chapters that illuminate the Foundation from the inside.

As is obvious from this summary, this year’s Robert Wood Johnson Foundation Anthology covers a wide range of initiatives to improve health and health care. If there is a common thread running through the chapters—at least a significant number of them, including those on nursing, tobacco control, and the end of life—it is the importance of knowing when to leave a program or a field, how to exit gracefully, and how and whether to sustain the work after the Foundation’s support has ended.

In the past, little thought had to be given to exit strategies and sustaining programs. This was, perhaps, because government could be expected to pick up the financing of successful programs, or because there was an expectation on the part of both grantees and Foundation staff that the Robert Wood Johnson Foundation’s support would continue indefinitely. So the focus in the past was on the replication of successful models and taking projects “to scale” so that government—preferably federal—would notice and ultimately support them. Moreover, in the generally good economic times that characterized much of the 1980s and 1990s, the Foundation’s resources kept growing. New programs were authorized, but many old programs continued. The Foundation began a large number of initiatives that did not have a natural endpoint, and it made open-ended commitments to grantees. Both new and perpetual challenges could, it seemed, be addressed simultaneously.

Changing times force new patterns of thinking. The economy is no longer growing as it did in the previous decades. The federal government has devolved the financing of social programs to states and localities; it is no longer expected to absorb even successful initiatives begun with foundation support. After a long period dedicated to examining its priorities, the Robert Wood Johnson Foundation made the decision to leave a number of fields, even as it is making long-term commitments to others.

All of these factors have led to a reconsideration of how long to continue funding programs and how to exit from them. As former Foundation president and chief executive officer, Steven Schroeder, quoting from the Kenny Rogers song, wrote, “You’ve got to know when to hold ’em; know when to fold ’em.” the Robert Wood Johnson Foundation does not have the answer (nor does anybody else) to the question of how long to stay with programs. What the Foundation has learned, however, is that a few years is probably not long enough to influence the development of a field or to bring about social change, and that it is necessary to think about sustainability from the earliest stages of program development. It has convened a staff task force, called “roots and wings,” to consider how best to leave programs and fields; is assisting some grantees in sustaining their efforts; and remains committed to finding ways to continue work begun with Foundation support that remains essential.