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GrantWatch

REPORT

Field Building: Lessons From The Robert Wood Johnson Foundation’s Anthology Series

Abstract

 
As editors of the Robert Wood Johnson Foundation’s (RWJF’s) anthology series, we have examined the entire range of the foundation’s grant making since 1972. We found that the RWJF has enjoyed considerable success in building fields—from nurse practitioners to tobacco control to end-of-life care. The RWJF has done this by shaping fields as they were emerging, by adopting a wide-ranging "bear hug" approach, and by staying the course. The lessons from the RWJF’s field-building efforts are relevant for both large and small foundations: Small funders can develop strategic plans aimed at building fields in their home state or locality.

As editors of the Robert Wood Johnson Foundation Anthology series, we are in the privileged position of having examined the entire range of one foundation’s grant making since 1972. We have observed eleven elements that go into successful grant making.¹ One of the most important is building fields. It is through field building that the Robert Wood Johnson Foundation (RWJF) achieved some of its most noteworthy successes, including those in tobacco control, the nurse practitioner (NP) profession, and end-of-life care.

In the field of tobacco control, for example, beginning in the 1990s, the foundation took a multiprong approach. Among other things, it funded a high-profile Washington, D.C.–based advocacy center, the Center for Tobacco-Free Kids, which played a visible role in the tobacco settlement negotiations and in reducing young people’s access to cigarettes; the SmokeLess States Program—housed in the American Medical Association—which financed and assisted state-based tobacco control coalitions that worked to improve policies at the state level; policy research that showed how higher tobacco taxes reduced smoking; initiatives to develop smoking-cessation standards for health maintenance organizations (HMOs); and public information programs, such as the National Spit Tobacco Education Program, which worked with Major League Baseball.²

In the mid-1990s, after a large RWJF-funded research study found that the wishes of hospitalized, terminally ill patients and their families were routinely ignored, the RWJF gave high priority to improving care for the dying.³ It funded initiatives that developed palliative care programs at major medical centers; increased the attention given to end-of-life care in medical and nursing textbooks; produced a series of articles in medical and nursing journals; and organized coalitions of people working to improve end-of-life care.⁴ Its efforts, and those of the Open Society Institute, a foundation established by George Soros, led the New York Times to conclude, "The sharp increase in research on death demonstrates the growing power of philanthropy almost to create an academic field."⁵

During the 1970s and 1980s, a similar wide-ranging approach helped bring about the acceptance of NPs as a viable health care profession. Soon after the RWJF became a national philanthropy in 1972, it financed a number of demonstration projects to show that NPs could provide care to people living in under-served areas. To strengthen NPs’ credibility and develop an academic training base, it then funded fellowship programs for nurses who would become the field’s academic leaders and gave funds to nursing schools that developed graduate-level NP programs. The foundation also commissioned research, supported the creation of a professional society, and funded communications campaigns.⁶

Field building is not easy and raises many issues. Which fields to enter? What are the most effective approaches? How long to stick with it? Why does a similar approach lead to successful field building in some cases and failure in others? The experience of the RWJF, as reflected in the pages of its anthology series, offers some guidance on ways to address these questions.

Selecting Fields

Top Selecting Fields The ‘Bear Hug’... Staying The Course Strengthening Research... Field-Building Success And... NOTES

 
Although every foundation wants to break new ground, it is not necessary to be the first out of the gate. Most of the RWJF’s field-building successes have come where it accelerated and shaped fields that were already emerging. Public recognition that cigarettes cause cancer goes at least as far back as an article in Readers Digest in 1952 and the surgeon general’s report in 1964. Many legal and regulatory challenges had already taken place when the RWJF entered the field in the early 1990s. Similarly, the problems with end-of-life care were already well known at the time the foundation decided to become involved. The 1970s and 1980s were, after all, the decades of the right-to-die movement, the Hemlock Society, and the landmark Karen Ann Quinlan court decision. By allocating substantial resources to this field, the foundation helped harness a movement that had been gathering steam for at least two decades.

Although it is not easy to know which fields are poised to take off, the best foundation leaders and program officers will have a sense—through conversations, reading, and observation—about emerging trends and the potential for foundation funding to affect them. At the moment, for example, it is a pretty good bet that obesity, quality of care, aging and chronic illness, and public health—already important to the nation’s health—are likely to become even more so.

The ‘Bear Hug’ Approach To Field Building

Top Selecting Fields The ‘Bear Hug’... Staying The Course Strengthening Research... Field-Building Success And... NOTES

 
The RWJF has been particularly effective when it embraced a field—in the sense of a bear hug—by using all of the tools at its disposal. In its work on tobacco control, for example, the foundation funded policy research, coalition building in states, advocacy groups, demonstration projects, conferences, standard setting, and public information campaigns. It worked with all levels of government, nongovernmental organizations, and voluntary groups such as the American Cancer Society. The RWJF became an active participant in the tobacco control debate, and the foundation’s then-president, Steven Schroeder, used his office as a bully pulpit.⁷ Although the RWJF’s tobacco-control work began as opportunistic, by the mid-1990s it had become far more strategic, and the foundation’s staff had consciously adopted a comprehensive approach to addressing the problem of smoking.

The RWJF’s efforts to improve end-of-life care, which began in the mid-1990s, were more targeted from their inception and sought, through a variety of approaches, to influence the way the medical and nursing professions thought about care of the dying, to change public attitudes, and to improve the care that hospitals provided to dying patients.⁸

Staying The Course

Top Selecting Fields The ‘Bear Hug’... Staying The Course Strengthening Research... Field-Building Success And... NOTES

 
There is no hard-and-fast rule about how long to stay with a field. It must be recognized, however, that social change does not come quickly and that a long perspective is needed. Although the RWJF has not found the secret of precisely how long to stay, it has learned both that a few years is too short to have a meaningful impact on social change and that to focus on a specific issue indefinitely is not a good idea.

In general, the RWJF has had a good record of staying with fields long enough for them to mature. For example, it has supported programs to enhance the field of generalist medicine for three decades. As far back as the 1970s the foundation funded programs to develop primary care residencies for graduate medical students in internal medicine, pediatrics, and family practice. In the 1990s it sponsored programs to strengthen the research capability of generalist physicians and to improve the teaching of generalist medicine in U.S. medical schools.⁹ In the field of health policy and services research, the foundation’s Clinical Scholars Health Policy Fellows program began in 1973. The Clinical Scholars program trains clinicians to do policy and health services research. Recently, the foundation’s leadership made a commitment to stay with the nursing and obesity fields for at least a decade.

This does not mean, however, that foundations should continue funding fields indefinitely. As former RWJF president Schroeder, quoting the Kenny Rogers standard, said, "You’ve got to know when to hold ’em, know when to fold ’em."¹⁰ So, after a decade of funding the tobacco and end-of-life fields, the foundation is phasing out its support and working to maintain the gains that these fields have seen. Not everybody agrees, however, that the foundation stays with a field long enough. Many experts in both the tobacco control and end-of-life fields have expressed concern about the foundation’s deemphasis of work in those areas. One concern, of course, is that problems in these fields persist. In both of these fields, the foundation believes it has stimulated change and new thinking and that it is time to move on to new challenges, even as it tries to help the committed professionals in these fields find other sources of funding and other strategies to continue their work.

Strengthening Research Capability And Scholarship

Top Selecting Fields The ‘Bear Hug’... Staying The Course Strengthening Research... Field-Building Success And... NOTES

 
The examples of field-building initiatives that we have used thus far are focused on specific problem areas. The foundation also takes the more general approach of strengthening academic or professional disciplines. Health policy and services research provides a good example. Fellowship and scholarship programs (such as Health Policy Fellows, Scholars in Health Policy Research, Investigator Awards in Health Policy Research, and the new Scholars in Health and Society)—as well as funding of research itself (through programs such as Changes in Health Care Financing and Organization [HCFO] and the Substance Abuse Policy Research Program)—have been an integral part of the foundation’s strategy to build a corps of researchers and scholars with expertise in health policy and services research.¹¹ These and other RWJF programs to strengthen human capital now account for approximately 15 percent of the foundation’s program spending.

Field-Building Success And Failure

Top Selecting Fields The ‘Bear Hug’... Staying The Course Strengthening Research... Field-Building Success And... NOTES

 
Why does one approach to field building succeed but a similar one does not? And even when a field is strengthened, why does it advance social change only some of the time? Smoking and health insurance offer an interesting contrast. The foundation’s efforts in tobacco control helped mobilize a field, but similar efforts to expand health insurance coverage—coverage expansion has been a foundation priority for decades—failed to take hold.¹² On its face, one would think that behavioral change such as giving up smoking would be much harder to bring about than political change such as making health care accessible.

In part, of course, foundations—even the largest of them—are relatively small players without the capacity to influence larger social trends. Even the millions of dollars that foundations spend to improve health and health care are hardly noticeable in a trillion-dollar-plus health economy.

But the issue goes beyond a lack of clout. The difference between success and failure may lie in the nature of the problem being addressed and the potential solutions to it. Smoking, for example, is widely recognized as harmful to health—the research is compelling, and the dangers have been widely publicized; there is a recognizable villain (Big Tobacco); and there is a simple, albeit difficult, solution (stop—or do not start—smoking). This combination of factors may explain why the remarkable change in Americans’ behavior—decreased smoking—occurred. On the other hand, reducing the number of uninsured people is not high on the nation’s political agenda; there is no easily identified villain; no consensus exists on what to do about the problem; and the issue is highly charged politically. It is not surprising that building an effective field focused on health insurance coverage—even with the RWJF-funded Cover the Uninsured Week, which brings together a wide range of individuals and organizations—has turned out to be tougher sledding than building one focused on tobacco control.¹³ Despite the difficulties, the RWJF continues its efforts to keep health insurance on the national agenda and to explore options for covering more people—in part because of its importance to health and in part because of the signal it would send should the foundation abandon the effort.

The need for a long-term perspective, the softness of concepts such as "field" or even "health," and the difficulty of disentangling results of a foundation’s efforts from those of other players or of society at large make it tricky to measure effectiveness. Even though social change and field building are harder to measure than profitability, the bottom line is still important, and foundations should assess the results of what they do. Over the past few years, the RWJF has tried to do this by establishing a variety of ways to evaluate and communicate the progress and the impact of its grants. Although the RWJF continues to evaluate its major programs—generally by measuring changes over time among program grantees relative to an appropriate comparison group—it also uses performance measurement systems to track the outcomes of most of its grants over the short and medium terms. The foundation has also developed analytical approaches, such as its anthology series and its Web-based reports of grant results, to assess long-term impact in a more qualitative manner.

Social change comes hard, and there is no single right way to do it.¹⁴ As the RWJF experience demonstrates, foundations are well positioned to strengthen fields that have the potential to improve health. Unlike businesses, they can identify emerging fields, take an all-encompassing approach to developing them, adopt a long-term view, and stay the course. This is true of large and small foundations alike. Just as large foundations may affect policies and programs nationally, state and local foundations have the same potential with policies and programs within their own geographic areas. Foundations with a statewide mandate, for example, can take a strategic approach by focusing on a few key issues and working with partners (both governmental and nongovernmental) to build fields at the state level. Local foundations, which often have considerable clout at the city, county, or regional level, similarly can concentrate their efforts and, working with others, develop fields in their geographic areas. Health philanthropy now has a great opportunity to both stimulate and be a part of social change.

Editor's Notes

 
Stephen Isaacs (sisaacs{at}chsp.org) is a partner in Isaacs/Jellinek, a firm providing consulting services to foundations. Jim Knickman is vice president for research and evaluation at the Robert Wood Johnson Foundation in Princeton, New Jersey.

Support for this paper was provided by the Robert Wood Johnson Foundation.

NOTES

Top Selecting Fields The ‘Bear Hug’... Staying The Course Strengthening Research... Field-Building Success And... NOTES

 

1. S.L. Isaacs and J.R. Knickman, "Observations on Grantmaking," in To Improve Health and Health Care: The Robert Wood Johnson Foundation Anthology, vol. 7, ed. S.L. Isaacs and J.R. Knickman (San Francisco: Jossey-Bass, 2004).
2. J. Bornemeier, "Taking on Tobacco: The Robert Wood Johnson Foundation’s Assault on Smoking," in To Improve Health and Health Care: The Robert Wood Johnson Foundation Anthology, vol. 8, ed. S.L. Isaacs and J.R. Knickman (San Francisco: Jossey-Bass, 2005).
3. J. Lynn, "Unexpected Returns: Insights from SUPPORT," in To Improve Health and Health Care, 1997: The Robert Wood Johnson Foundation Anthology, ed. S.L. Isaacs and J.R. Knickman (San Francisco: Jossey-Bass, 1997).
4. E. Bronner, "The Foundation’s End-of-Life Programs: Changing the American Way of Death," in To Improve Health and Health Care: The Robert Wood Johnson Foundation Anthology, vol. 6, ed. S.L. Isaacs and J.R. Knickman (San Francisco: Jossey-Bass, 2003).
5. J. Miller, "When Foundations Chime In: The Issue of Dying Comes to Life," New York Times, 22 November 1997.
6. C. Newbergh, "The Robert Wood Johnson Foundation’s Commitment to Nursing," in To Improve Health and Health Care, vol. 8; and T. Keenan, "Support of Nurse Practitioners and Physician Assistants," in To Improve Health and Health Care, 1998–1999, The Robert Wood Johnson Foundation Anthology, ed. S.L. Isaacs and J.R. Knickman (San Francisco: Jossey-Bass, 1998).
7. Bornemeier, "Taking on Tobacco"; K.K. Gerlach and M.A. Larkin, "The SmokeLess States Program," in To Improve Health and Health Care, vol. 8; D. Diehl, "The Center for Tobacco-Free Kids and the Tobacco-Settlement Negotiations," in To Improve Health and Health Care, vol. 6; and N.J. Kaufman and K.L. Feiden, "Linking Biomedical and Behavioral Research for Tobacco Use Prevention: Sundance and Beyond," in To Improve Health and Health Care, 2000: The Robert Wood Johnson Foundation Anthology, ed. S.L. Isaacs and J.R. Knickman (San Francisco: Jossey-Bass, 1999).
8. V. Weisfeld et al., "Improving Care at the End of Life: What Does It Take?" Health Affairs 19, no. 6 (2000): 277–283.
9. S.L. Isaacs, L.G. Sandy, and S.A. Schroeder, "Improving the Health Care Workforce: Perspectives from Twenty-four Years’ Experience," in To Improve Health and Health Care, 1997.
10. R. Schapiro, "A Conversation with Steven A. Schroeder," in To Improve Health and Health Care, vol. 6, 25.
11. R.S. Frank, "The Health Policy Fellowships Program," in To Improve Health and Health Care: The Robert Wood Johnson Foundation Anthology, vol. 5, ed. S.L. Isaacs and J.R. Knickman (San Francisco: Jossey-Bass, 2002); and D.C. Colby, "Building Health Policy Research Capacity in the Social Sciences," in To Improve Health and Health Care, vol. 6.
12. C. Newbergh, "The Robert Wood Johnson Foundation’s Efforts to Contain Health Care Costs," in To Improve Health and Health Care, vol. 7; R. Frank, "The National Health Policy Forum," in To Improve Health and Health Care, vol. 7; C. Newbergh, "The Health Tracking Initiative," in To Improve Health and Health Care, vol. 6; S. Garland, "The Covering Kids Communications Campaign," in To Improve Health and Health Care, vol. 6; and M.Y. Holloway, "Expanding Health Insurance for Children," in To Improve Health and Health Care, 2000.
13. S. Isaacs and M. Frank, "Foundations and Health Reform: Meeting the Challenge," Journal of the Association for Healthcare Philanthropy (Fall 2004): 22–25.
14. S. Isaacs and S. Schroeder, "Where the Public Good Prevailed," American Prospect (4 June 2001): 26–30.

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