Editors’ note: This article is reprinted from the Summer 2017 edition of the Nonprofit Quarterly, “Nonprofit Graduation: Evolving from Risk Management to Risk Leadership.” It was first published by Health Affairs as a blog, on June 6, 2017. It is reprinted with permission from the authors and Health Affairs, with minor alterations.1
Working on advocacy and policy is challenging. Not only is it complex, fluid, and increasingly politicized, it is also challenging to measure progress and communicate success.
Understanding this, in 2012, the Foundation for a Healthy Kentucky, a state-wide foundation located in Louisville, launched Promoting Responsive Health Policy (PRHP), a six-year, multifaceted initiative to address four broad health policy areas: increasing access to integrated healthcare; increasing the proportion of Kentuckians living in smoke-free jurisdictions; improving children’s health; and strengthening local public health.2
Building on past investments, the foundation engaged a variety of grantees and contractors as partners: legal, youth, and consumer advocates; researchers; and communications and media organizations. The Center for Community Health and Evaluation (CCHE), located in Seattle, Washington, and affiliated with Kaiser Permanente, was selected to serve as the external evaluation partner because of its experience evaluating policy work and its developmental approach to evaluation.3
Halfway through PRHP, a change in state leadership prompted dramatic changes in the political climate and in policy positions coming from the governor. These changes meant that PRHP’s policy goals, especially around the Affordable Care Act (ACA) and efforts toward passing a comprehensive state-wide smoke-free law, were at odds with the new governor’s goals.4 These changes had profound impact on the foundation and its grantees, requiring all players to reassess their strategies and make substantive adjustments.
The foundation’s approach, combined with the dynamic policy environment, provides a unique opportunity to examine and share lessons learned (addressed more fully in the final report on the PRHP evaluation).5
Recognizing the complexity of the policy issues and taking a broad approach to policy change, the foundation approached PRHP using four key strategies:
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- Requiring use of the following characteristics of effective, high-quality grantmaking. Trust: The foundation’s partnership approach to grantmaking enabled it to provide the needed flexibility for grantees to be responsive to political changes. This approach depended on trust and long-term relationships with and among grantees.
Flexibility: An adaptive and multipronged approach allowed the foundation and its grantees to be agile in a rapidly changing policy environment.
Diverse strategies: Having a diverse cadre of partners made a variety of tools available to the foundation, and that was particularly useful when tactics had to be adapted to the changing political landscape.
Collaboration: As a result of the foundation’s efforts to promote collaboration among partners, grantees reported increased connections with other partners.
Capacity building: Investing in organizations through multiyear grants, trainings, and technical assistance (in addition to sharing findings from foundation-funded research projects) deepened and strengthened the advocacy infrastructure in Kentucky.
- Acting as a convener, which was consistently identified as one of the most effective ways the foundation informed policy. Evaluators found that “stakeholders described the valuable and unique role the Foundation plays in informing health policy in Kentucky as a non-partisan, independent organization.”6 The foundation brought local and national speakers to inform local health policy discussions and facilitate difficult conversations, guided by research and best practices, in a safe, neutral space.
- Investing in data and research, which was the foundation’s key contribution to health policy. Grantees and key stakeholders identified the annual Kentucky Health Issues Poll and the multiyear study on the impact of the ACA, which was conducted by the State Health Access Data Assistance Center (SHADAC), as integral and valuable in grounding advocacy efforts in facts.7 As noted by evaluators, “investments in convenings and data were identified as examples of how the Foundation could leverage its resources to be responsive to emerging policy issues and to bolster the capacity of advocates, particularly grantees.”8
- Using communication and messaging for effective policy and advocacy work. The foundation increased its own communications capacity to support grantees and highlight grantees’ work. The foundation also offered media training and assistance with messaging around complex health policy issues, and its communication grantees translated policy issues for the mainstream media and diverse stakeholders without health policy expertise.
While the foundation was, in fact, able to apply what it had learned from prior advocacy initiatives, working in a time of a rapidly changing policy landscape presented some challenges, including the following:
- Lack of clarity on policy positions and the foundation role. Changes in state government leadership placed the foundation at odds with prevailing state policy directions, which uncovered a lack of clarity on specific policy positions among members of the foundation’s staff and governance committees. This was compounded by an ongoing deliberation regarding the foundation’s advocacy role. While the foundation made a decision to be an operating foundation as well as a grantmaking foundation, it was less clear how public the foundation would be on increasingly politicized policy issues.
- Maintaining alignment with grantees. Organizations took different positions as to how oppositional they would be to the new state administration. This divergence created tensions between and among the foundation and its grantees, and in response, the foundation developed mechanisms to maintain connections and alignment with key partners. As an example, the foundation created and led a working group of grantees and other partners to identify opportunities and strategies for coordinating and collaborating efforts to sustain the health policy wins from the past few years (such as Kentucky’s Medicaid expansion, the state-based health insurance exchange, and the tobacco-free policy on state government property).
- Breadth versus depth. ACA implementation created unique policy opportunities for PRHP to contribute to Kentucky’s success in outreach and enrollment. This focus, however, tilted foundation resources and staff capacity to one of its four policy priorities, thereby limiting the investments made in the other priorities. If the foundation had had a narrower policy focus, it might have had an even greater impact on state health policy.
- Differing definitions of success for the initiative. PRHP used a “policy spectrum” framework, which allowed for a broad understanding of policy and incorporated a wide array of strategies and tactics.9 While this was embraced by grantees and foundation staff, there was a “strong focus from the Foundation’s board on judging impact primarily through policy enactment,” the final PRHP evaluation report said.10 This divergence in how policy (and policy success) was defined became more pronounced as the initiative progressed.
The successes and challenges experienced throughout PRHP provided the foundation with lessons on how best to pursue policy change through investments by philanthropy and how funders can make policy more responsive to the needs of the communities they serve. Recommendations from the evaluation included the following:
- Clearly identify policy priorities and understand potential trade-offs between a broad set of policy priorities and more focused policy goals.
- Articulate the funder’s role in the initiative, including the level of engagement in direct policy work and how policy positions will be developed. Depending on the legal structure of the foundation, funders will need to be clear on their ability to lobby and the extent to which they can engage in lobbying.
- Align the focus and structure of grants with the necessary expertise and strategies [such as flexibility] needed to respond to the dynamic policy environment. For example, for a health policy initiative such as PRHP, both the foundation staff and the grantees should have expertise in health policy. And it is also important to contract with experienced researchers who can provide data and research findings to the foundation, grantees, and interested members of the general public.
- Build awareness of the broad spectrum of strategies needed to develop, enact, and implement policy.
- Consider long-term investments to build infrastructure in key partner organizations.11
- Gabriela Alcalde and Maggie Jones, “Investing In Policy And Advocacy: A Foundation Shares Lessons Learned,” Health Affairs Blog, June 6, 2017.
- “Promoting Responsive Health Policy (PRHP),” Foundation for a Healthy Kentucky.
- Jamie A. A. Gamble, A Developmental Evaluation Primer (Montreal, Quebec: J.W. McConnell Family Foundation, 2008).
- Michael A. Tynan et al., “State and Local Comprehensive Smoke-Free Laws for Worksites, Restaurants, and Bars—United States, 2015,” Morbidity and Mortality Weekly Report (MMWR) 65, no. 24 (June 24, 2016): 623–26, Centers for Disease Control and Prevention; and Morgan Watkins and Tom Loftus, “Bevin’s first year: Policies and controversies,” Courier-Journal, December 10, 2016.
- Toward a Healthier Kentucky: Using Research and Relationships to Promote Responsive Health Policy: Lessons for the Field (Louisville, KY: Center for Community Health and Evaluation, March 2017).
- “Kentucky Health Issues Polls,” Foundation for a Healthy Kentucky; and “First Year Report Tracks Affordable Care Act Impact in Kentucky,” Foundation for a Healthy Kentucky, March 7, 2016.
- Toward a Healthier Kentucky, 6.
- Ibid., 7–8.
- Ibid., 8.
- Ibid., 10.