Sustaining Frontline Change in Healthcare and Beyond: Lessons from Advancing Health Equity

With severe cuts to public health infrastructure and growing uncertainty about philanthropy’s financial footing, nonprofit leaders—executive directors, foundation program officers, and other funding decisionmakers—must think beyond the grant cycle to sustain health equity programs. This is especially true when their work addresses deep-rooted stigma and entrenched systems.

Too often, once the funding is awarded, the real work of implementation is left to frontline teams without the support, infrastructure, or sustainability plan needed to make the program last.

Drawing from our experience in providing oversight of program implementation and grant funding, we see clearly how this pattern plays out in healthcare delivery, especially emergency care. The result is costly and inefficient. And now more so than ever, it devastates health equity work. When a program ends, and the change doesn’t stick, a patient loses access, and a community loses the progress it worked hard to gain.

Too often, once the funding is awarded, the real work of implementation is left to frontline teams without the support, infrastructure, or sustainability plan needed to make the program last.

The good news is that new research-backed frameworks are being deployed to support implementers working in unstable times. One example is the changemaking framework developed by the Bridge Center (Bridge)—a program of the Public Health Institute in Oakland, CA. Over six years, Bridge directly funded hospitals to implement emergency department (ED)—based substance-use disorder treatments. The model draws from proven strategies to decrease preexisting bias, to use evidence-based practices for addressing stigmatized health conditions, and to create sustainable reform in acute care settings. And this guidance extends well beyond healthcare—it offers lessons for funders and nonprofit leaders seeking to sustain change, while developing strong implementation experience.

We Know Health Equity Infrastructure Works

Today, EDs are the most accessible entry point into the US healthcare system, especially for patients experiencing low socioeconomic status and other barriers to outpatient care. EDs operate 24 hours a day, seven days a week, with a federal mandate to never turn anyone away. And this infrastructure is essential. One-fifth of the people who utilize EDs report having no other source of healthcare. Yet EDs are largely underresourced and underequipped for the public health role they are already playing.

Bridge leads strategic efforts to address these gaps by transforming practices in EDs, thus supporting their work in providing evidence-based addiction treatment, reproductive healthcare, and sexually transmitted disease services to patients who have nowhere else to go. Through our efforts, we’ve learned change is hard. Yet, even amid the most complex challenges, change is possible.

The results of intentionally transforming organizational practice are real and hard-won. With Bridge’s grant support, emergency departments in California meaningfully addressed stigmatized health conditions by providing buprenorphine treatment to more than 45,000 patients with opioid use disorder. EDs are also implementing routine opt-out testing and linkage to treatment for communities disproportionately impacted by infectious diseases such as syphilis, HIV, and viral hepatitis. And now, in the era of post-Dobbs v. Jackson, EDs are becoming a critical access point for medication abortion and contraception, including at hospitals far from traditional family planning sites. Together, these initiatives are active across hundreds of hospitals in over 40 states, representing new infrastructure built over years of navigating institutional inertia, shifting policies, and fragile funding.

Programs should anchor solutions in their day-to-day realities of frontline staff.

Given the current political landscape, that infrastructure is now at risk. Bridge is just one example of many initiatives that have made great strides but are grappling with sustaining the work amid funding retrenchment. Federal funding cuts have moved at lightning speed. The lead agency for funding mental health and addiction treatment programs was reduced by 50 percent in 2025, and family planning programs have been decimated at global and local scales.

Making It Last: Strategies for Sustaining Your Program’s Impact

Nonprofits working on the frontlines for health equity play a vital role in turning persistent challenges into progress through their community-centered work. Funders also play a critical role by resourcing this work and cultivating cross-sector collaboration, helping build an ecosystem and the systems change needed to carry this work through long-term.

To shift practice and systems, we recommend nonprofit leaders to:

• Support your teams by designing for the frontline: Programs should anchor solutions in the day-to-day realities of frontline staff. Before finalizing any program deliverable, name the specific context in which your frontline team will use it. Consider factors that influence their ability to provide services, such as the time of day, their competing demands, and the available technology.

As part of Bridge’s work, we strategized with ED leaders to determine what is feasible and how to facilitate a level of change that will become normalized and enduring. We tested every deliverable against a single question: Would this actually work at 2 am in a busy ED? Emergency physicians make life-or-death decisions in under two minutes. Any program asking them to change their practice must meet them in that reality.

Onerous reporting requirements have real costs: they slow down implementers and crowd out the actual work.

We haven’t always gotten it right. One education initiative supporting medication abortion initiation assigned a textbook chapter as reading material. Busy emergency physicians told us they clicked on the chapter, saw a “sea of words,” and closed the tab. A training format that our champions don’t engage with is a failed training. We switched instead to a video lecture, which has received great reviews.

We’ve learned that if a program expects changes in how people work, those changes should be designed from their perspective.

• Right-size data collection to fit program goals: Onerous reporting requirements have real costs: they slow down implementers and crowd out the actual work. Power dynamics between grantmakers and grantees lead many nonprofit leaders or program managers to go extra lengths to stay in and even above compliance with their awards.

When Bridge’s California ED buprenorphine program was scaling, every team had a hypothesis they wanted to test and a survey metric to match. One midpoint survey ballooned to over 50 data points, which places a heavy burden on the data collectors often working on care expansion on top of their full-time job. We course-corrected by tying every data point back to the program’s core aims and committing to collect only what we had a genuine plan to use.

We recommend writing one sentence for every data point you collect, describing the decision it will inform. If you can’t write that sentence, cut the metric.

The same goes for required meetings. Bridge recently balked at a grant application that required two meetings per month with a funder offering a modest dollar amount. We recommend describing the way every meeting will inform the desired goal. If it’s not clear, cut the requirement, and let your frontline leaders implement.

• Build sustainability as a deliverable from the start: Grants end. Yet we want the program impact to last. This can only be achieved when the work goes on after the grant ends. That is, specific plans for what survives the grant funding cycle should start on day one.

For Bridge’s ED programs, that meant building tools that grantees could own and operate independently, like a spreadsheet with a built-in algorithm that allowed hospitals to generate their own return-on-investment reports for hospital leadership. These reports detailed the cost-savings attributed to ED-based substance use interventions, demonstrating the value of continuing the program beyond grant end dates. When Bridge successfully advocated for a new Medicaid benefit supporting ED-based patient navigation services, we awarded funding to hospitals willing to test and document the benefit to understand how to turn a policy win into a permanent financing mechanism.

Asking how your program would survive if funding disappeared tomorrow should be built into planning before launch. Right now, any healthcare organization that sees Medicaid patients should be working to understand the impacts of the current administration’s policy changes on who is and isn’t eligible for coverage. While the anticipated cuts are expected to be substantial, there are many steps organizations can take to protect patients from losing coverage, including comprehensively diagnosing conditions that are eligible for exemptions.

• Advocacy is part of the job; leverage your coalition partners: With federal support for health equity work under pressure, advocacy is not optional. Leaders can map the one policy or payment change that would do the most to sustain your program’s impact after the grant ends. Then make advocating for that change a line item in your workplan.

At Bridge, that one policy change was the creation of a new Medicaid reimbursement pathway for patient navigation services that is now a covered benefit. The work didn’t end when the benefit went live, we are actively working on technical assistance to increase uptake of this mechanism to sustain lifesaving patient care.

The best advocacy is done when you can partner with coalitions to build collective impact. Bridge represents just one corner of the healthcare landscape. Through coalitions such as the Reproductive Health Service Corps, we expand our partnerships to include nursing advocates, pharmacists, midwives, and prescribers beyond emergency medicine. We are also proud to be a member of the Health Equity Workgroup at Clinton Global Initiative (CGI), introducing us to partners far beyond the traditional healthcare landscape.

Here Are Three Things Foundations Can Do Now

• Support great leaders to thrive long-term: The demanding work of frontline implementers can often lead to burnout, making it essential to think creatively about long-term support beyond what traditional nonprofit budgets typically cover. The pressures are real and well-documented: nonprofit leaders are contending with chronic underfunding, staffing shortages, and the emotional weight of working on deeply complex social challenges. According to the Center for Effective Philanthropy’s State of Nonprofits 2024: What Funders Need to Know report, 95% of nonprofit leaders expressed some level of concern about burnout, and 76% said that staff burnout was at least slightly impacting their organization’s ability to achieve its mission.

Think about creative ways to bolster the impact and expand the network of your nonprofit partners beyond financial contributions. The good news is there are examples of this work already underway.

The Black Feminists in Philanthropy network, made up of over 350 Black women and gender-expansive people working across foundations and wealth advisory roles worldwide, has modeled what it looks like to go beyond the grant: convening regularly to pool strategic intelligence, acting as absorbers who translate between institutional bureaucracy and movement needs.

When it comes to rapid response, Nonprofit Quarterly’s field guidance is equally direct: if your foundation cannot move funds quickly, that is not a reason to opt out—foundations can partner with intermediaries and pooled funds already holding the work, and allow grantees to quickly access emergency resources for legal defense, crisis communications, and other needs that cannot wait for the next grant cycle.

At CGI, we ensure all commitment partners can attend our Annual Meeting each September, where they can connect with changemakers from around the world and bring renewed energy back to their work. In 2025, we also implemented working sessions where partners could roll up their sleeves and work together to identify solutions to our most pressing challenges, including the issues facing maternal and reproductive healthcare access across the US and globally. It is no secret that young men shifted right in the last election cycle and that while 61 percent consider themselves pro-choice, they remain passive on the issue. One partner who tackles young men’s engagement in pro-choice advocacy participated in the working session and was able to make several concrete connections with some of the leading organizations in this space to share resources and find ways to mutually reinforce each other’s work.

• Develop Collaborative Networks: Foundations have broad networks and can see across organizations, communities, and issues in a way that an individual grantee cannot. Connecting like-minded implementers and communities creates space for cross-pollination of ideas, sharing best practices, and identifying new opportunities for coordination, especially when resources are limited.

Consider how you can identify aligned organizations working towards similar goals and help build strong connections among them, so they are able to reinforce and support one another.

Lasting impact requires designing for sustainability from the start and embracing innovative approaches for lasting engagement.

CGI’s model is rooted in building partnerships and uncovering new pathways to mobilize action through 1:1 matchmaking, convenings, and the creation of action networks for ongoing collaboration. Over three years, we’ve supported the Reproductive Justice Action Network that brought together funders, practitioners, and community-based organizations to share best practices, exchange lessons learned, and identify opportunities for collaboration and partnerships. Partners through this network have collectively mobilized 10.5 million dollars for maternal and reproductive health in the US.

• Leverage your credibility to spark conversations: Use your platform to be a vocal advocate for the issues that your implementing partners are addressing and think about how you can bring additional resources and attention to the topics to create lasting engagement and impact. Now more than ever, it’s important that foundations use their platform to amplify the voices of grant partners and drive broader conversations about the systemic issues that they address.

At CGI, we prioritize cross-sector convenings, like our Working Group model, to elevate these perspectives, bring together unlikely partners, and foster creative, collaborative solutions, and have always prioritized reproductive health and rights as part of these conversations. One partner working on reproductive and maternal health payment reform was so motivated by the diverse mix of participants, including policy practitioners, clinicians, grassroots advocates, and funders, that she identified a new initiative to promote transparency in coverage and drive systemic impact.

Lasting impact requires designing for sustainability from the start and embracing innovative approaches for lasting engagement. We call on all executive directors, foundation program officers, and others in leadership roles to consider these strategies. The investment you make today is only as strong as what it leaves behind.