As the year 2015 came to a close, we touched the halfway point of our 10-year Building Healthy Communities (BHC) strategic plan. This plan focuses on improving the conditions under which young people in underserved communities can be healthy and thrive. As you know, a significant portion of the plan involves “place-based” attention on 14 communities across the state. Of equal importance is how the collective learning and energy from these communities contribute to statewide policy and systems change to promote health, health equity and health justice. BHC is a place-based strategy, but with an attitude for statewide change—we call it “place-based-plus” in shorthand.
How are we defining “success” for BHC? For us, the key goals (indicators) of success will not be limited to an arbitrary 10-year timeline. It will be when three things happen to benefit the health of young people in lower-income communities in California:
100% coverage and access to health-promoting health services
100% of California schools have wellness and school climate policies and practices
100% of California cities and counties establishing local health-promoting policies and moving from incarceration to prevention
The thinking behind these three targets for policy and systemic change: the wellness of young people is optimized when the “systems” they encounter—the health care system, the school, and the neighborhood—are supporting what families want and need for their children’s health and well-being.
However, we know achieving these policy milestones will represent only surface manifestations of the ultimate success we are seeking. That will be when the power dynamics in the communities have shifted to such an extent that families will be able to hold local officials accountable for full, ongoing implementation of these policies.
Already, thousands of community residents—adults and young people alike—are stepping up to take on this challenge. They are demonstrating courageous leadership. What they are accomplishing in their neighborhoods, at the state level, and in their online communities exceeds all our initial expectations. They are the heroes of the unfolding story of Building Healthy Communities.
We now have five years of implementation under our belt, plus a year or more of planning. We commissioned three independent reviews of our progress, lessons and mistakes. Over the past year, we reviewed the reports with our Board and staff, we listened to and learned from our community partners and we got busy making needed adjustments.
This document communicates our progress, lessons learned and key changes. We do so in the spirit of accountability to three sets of audiences: the community leaders with whom we work, the fields of philanthropy and public health, and ourselves as an organization.
What Has Been Achieved?
Those among us in the field of social-change investing recognize that ascribing positive impact to a specific grant, set of grants, or grant-making strategy is a pretty tricky business; the matters of “attribution” and “contribution” must be carefully navigated. That said, the following is a top-line listing of key results where BHC grantees, with The Endowment’s partnership support, have made a significant contribution towards impact:
1. Improved Health Coverage for the Underserved. BHC grantees and partners fought for and supported the successful implementation of the Affordable Care Act and the expansion of Medicaid in California.
2. Strengthened Health Coverage Policy for the Undocumented. BHC grantees and partners successfully crafted and led the #Health4All Campaign, paving the way for state-supported health coverage for undocumented children.
3. School Climate, Wellness and Equity Improvements. BHC grantees, partners, and youth led or supported efforts across the state to reform harsh school discipline and suspension policies, and are working to successfully implement school equity funding formulas.
4. Prevention and Reform Support in the Justice System. BHC grantees and partners led advocacy support for health- and prevention-oriented justice reform, and are leading Prop 47 implementation efforts statewide; one of the key objectives is to funnel prison savings into prevention strategies.
5. Public-Private Investment and Policy Changes for Boys & Young Men of Color. BHC grantees joined with other coalitions supporting outcome improvement work in young men of color, bringing improved public policy and civic attention to the issue, and resulting in the creation of a Select Committee on the Status of Boys & Men of Color in the state legislature.
6. Local & Regional Progress, “Health in all Policies.” Perhaps the most productive aspect of BHC progress resides in the more than 100 local policies and system change developments led by local BHC grantees, promoting a culture of “health in all policies” in local jurisdictions: more walkable communities, fresh food access, park space, access to clean drinking water, etc.
Overall, We Learned The Following About Our Progress
The top-line lesson for us has been a crystal-clear affirmation about the importance of leaders in underserved and lower-income communities flexing the civic and political power required to affect health-promoting systems change. For all of the attention heaped upon the roles that “good data,” “research effectiveness,” and “innovative approaches” have in driving public policy, the building of healthier communities is fundamentally a game of power, voice and advocacy. Plugging the voice of community into the right kind of political power grid will do more to create health and wellness than any other single intervention.
Our “theory of change” to help communities and health advocates assert power in economically challenged communities actually works. We have invested a substantial amount of grant dollars funding key “Drivers of Change” for grantees at the state and local levels: People Power, Youth Leadership, Collaboration, Partnerships, and Narrative Change. Community engagement has ranged from solid to excellent across the BHC spectrum, levels of trust between communities and our foundation are improving, and we have some local and statewide results to show for it.
Local BHC and Statewide Campaigns Have Taken Flight
Locally, residents and leaders led efforts to shape “health in all policies” approaches, scoring more than 100 victories across the sites in land use planning and walkable communities, healthy eating and wellness policies in schools, public health emphases in municipal and county General Plans, as well as new skate parks, soccer fields and after-school programs for children and youth. Institutionally, we have developed a sharper understanding about the role a private foundation can play in supporting a community-driven and community-engaged campaign.
On the statewide front, residents and youth leaders joined hands to advance healthier school climate policies, educate and enroll uninsured residents into the ACA and Medicaid expansion opportunities (we are proud to have contributed to California’s success in the ACA and Medicaid expansion enrollment), successfully advocate for undocumented residents to have access to affordable, quality health care, and push for more prevention-oriented law enforcement and criminal justice reforms.
All 14 BHC sites have experienced progress at varying levels. Early bumps and bruises experienced in several sites were managed through a combination of patience, improved communications, candor and trust building. Any fears experienced about needing to “drop” any troubled sites have been averted. As a result, we are now trusted across the sites to stay the course and not flee at the first sign of difficulty.
Youth engagement in and across the 14 sites has been a particularly strong point. All sites have young people meaningfully engaged at the table, and youth organizing to promote health is emerging as a signature hallmark of BHC. That said, we have also learned through young people directly communicating their experiences—and backed up by the data—that they are coping with substantial levels of stress, adversity and trauma in their daily lives. The depth of the issues of toxic stress, exposure to trauma, and resiliency in young people of color and young people in poor, white, rural communities—and its collective effects on their wellness—represents a major “discoverable” in the BHC journey. Based on the combination of the emerging science and the emerging voices of advocates for young people of color, exposure to trauma and stress is a significantly under-recognized public health crisis in this nation.
Thoughts for Our Colleagues in Philanthropy
In a sentence: You have to think about place, narrative change and power. These are, prodded by questioning from evaluation consultant Frank Farrow, the key “story lines” of BHC at the mid-point.
“Place” is where inequality, inequity, injustice, and exclusion all reveal themselves; these issues are real, tangible, palpable and visceral for communities. It is also where matters of courage, leadership, innovation and hope show themselves. Working at the level of neighborhood does not permit philanthropy to “whistle while walking though the cemetery”— pretending that matters of race, ethnicity, and various “-isms” can be ignored, overlooked, or glossed over. Even in the most well-intended grant-making strategy, addressing the needs of underserved communities, any logic model or theory of change that fails to consider race, or class, or context, or power, is fundamentally flawed and intellectually dishonest. There is a very good reason why America’s most accurate predictor of life expectancy is one’s zip code —place matters.
At the five-year mark of BHC, we have benefited tremendously, learning a great deal about building the capacity of community and advocacy organizations to fight needed battles for wellness. While we would not expect or encourage philanthropic institutions to select 14 different communities for long-term partnership investment, we can say—with the learnings that a half-billion dollars in grants have brought us—pick a neighborhood or two, stick with and by the leaders there, and learn and grow together.
“Narrative” is admittedly an elusive term, but we have experienced and witnessed the value of narrative change in advancing meaningful progress in policy and practice. When we supported the activities of grantees working directly with undocumented young people, and they began to directly express their voice, enthusiasm and energy for contributing to a more vibrant California, this was a game changer with respect to public and political attitudes about immigration and health in our state (and yes, we tracked polling numbers precisely on this question). The second example was with school discipline reform, when young people of color themselves owned and shaped the policy messaging about needed reforms.
Thirdly, we in philanthropy need to be much more assertive and comfortable about power-building and advocacy. The science and data about effective strategies is necessary, but hopelessly insufficient in America’s political and policy landscape. In short, we need to help community leaders on the front lines of the battles against inequality get more effectively political about what the science, and their own experiences, tell them what works.
Lastly, while the work of place, policy and inequality is exhilarating, it is difficult, and it is hard. Faithfully executing a logic model that doesn’t fit in a test tube, and is subject to all manner of political and civic developments operating at multiple levels, is simply not for the faint of heart. We wish we could impart some wisdom that simplifies how to address health inequality in a meaningful, sustainable fashion. It’s simply not that easy, but the path begins with a greater appreciation of advocacy, voice and power-building at the level of community: civic engagement on steroids.
Thoughts for Our Colleagues in Public Health and Public Agencies
Similar to our observations for colleagues in the field of philanthropy, assuring the conditions under which populations can thrive and be healthy requires a lens framed by matters of equity and power. It is fundamentally clear that social exclusion, marginalization, inequality, civic disengagement and hopelessness have a lethal effect on community health. By the same token, inclusion, engagement, power-building and civic voice lay the groundwork for the reduction of health disparities and closure of the gaps in health status.
What does this mean for local and regional public health specifically, and our health delivery system generally? It means that public institutions and agencies at the local level must be more attentive to and intentional about meaningful, engaged listening. They need to listen to community members, especially young people—“good, hard listening” if you will—and pay as much heed to the voice and experiential wisdom of community leaders as they do to the federal and state funding streams that shape their work.
Now that we have reached the five-year point, our Board of Directors is interested in having us embark on a year-long process of gathering feedback from grantees, community leaders, and civic leaders regarding the progress and lessons of BHC. We certainly remain committed to the work of BHC at least into 2021, and we welcome feedback about how to optimize the statewide impact and results of BHC, and the implications for our own planning and investment strategy beyond 2020. Thank you for contributing to the success of BHC, and we are indebted to the thousands of grassroots and community leaders who are leading the charge for a healthier, more inclusive California.
The California Endowment Board of Directors
Bishop Minerva Carcaño
Robert K. Ross
President and CEO
Our special thanks to Tom David and Frank Farrow for the coherence of this report, which would have been impossible without their brilliant guidance, insight and thoughtful observations. We are enormously indebted to the two of you.