FUNDING HEALTH ADVOCACY - GIH

FUNDING HEALTH ADVOCACY

I S S U E B R I E F N O . 2 1

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B A S E D O N A

G R A N T M A K E R S

I N H E A L T H

I S S U E D I A L O G U E

W A S H I N G T O N , D C

I S S U E B R I E F N O . 2 1

F E B R U A R Y 2 0 0 5

B A S E D O N A

G R A N T M A K E R S

I N H E A L T H

I S S U E D I A L O G U E

W A S H I N G T O N , D C©2005 Grantmakers In Health. All materials in thisreport are protected by U.S. copyright law. Permissionfrom Grantmakers In Health is required to redistributethis information, either in print or electronically.

This publication is available on-line at www.gih.org.

FUNDING HEALTHADVOCACY

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work to support grantmakers in theirefforts to fund policy-relevant projects andbuilds upon GIH’s track record of work ongrantmaker strategies for shaping publicpolicy.

Special thanks are due to those who partic-ipated in the Issue Dialogue, especially topresenters and discussants: Nan Aron,founder and president of the Alliance forJustice; Stefan Harvey, assistant director atthe California Center for Public HealthAdvocacy; Laura Hogan, program directorat The California Endowment; RuthHolton, director of public policy at TheCalifornia Wellness Foundation; TerriLangston, director of programs at thePublic Welfare Foundation; Sylvia L.Quinton, cocoordinator of the PrinceGeorge’s County Health Action Forum;Margaret O’Bryon, president of theConsumer Health Foundation; and SusanSherry, deputy director at CommunityCatalyst.

Rea Pañares, program associate at GIH,planned the program, wrote the back-ground paper, and synthesized key pointsfrom the Issue Dialogue into this report.Anne Schwartz, vice president of GIH,moderated the Issue Dialogue and provid-ed editorial assistance. Judith Meredith ofThe Public Policy Institute also con-tributed to this report.

This program and publication were madepossible by grants from The CaliforniaEndowment and Missouri Foundation forHealth.

As part of its continuing mission to servetrustees, executives, and staff of healthfoundations and corporate giving pro-grams, Grantmakers In Health (GIH)convened a group of experts from thefields of philanthropy, advocacy, and policyon November 3, 2004 to explore effectivestrategies for funding health advocacy.During this day-long Issue Dialogue, participants engaged in an open exchangeof ideas and perspectives on this importanttopic.

This Issue Brief synthesizes key pointsfrom the day’s discussion with a back-ground paper previously prepared for IssueDialogue participants. It focuses on thechallenges and opportunities involved withfunding advocacy and engaging in publicpolicy work. Sections include: the distinc-tion between public policy and advocacy;the legal framework for funding andengaging in advocacy, including lobbyingactivities; the motivation for philanthropicinvestments in advocacy and factors toconsider in the decisionmaking process;challenges and solutions to making thecase for initial and sustained funding ofadvocacy; tools and strategies for effectiveadvocacy, and grantmaker activities to sup-port them; evaluating grants for advocacyand policy; and finally, the lessons learnedfrom engaging in this work.

While the Issue Dialogue dealt largely withfunding health advocacy, this report andthe discussion at the Issue Dialogue con-sider advocacy as one of several strategiesfor affecting policy decisions. This IssueBrief also complements GIH’s ongoing

Foreword

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The mission of Grantmakers In Health(GIH) is to help grantmakers improve thenation’s health. GIH seeks to build theknowledge and skills of health funders,strengthen organizational effectiveness, andconnect grantmakers with peers andpotential partners. We help funders learnabout contemporary health issues, theimplications of changes in the health sectorand health policy, and how grantmakerscan make a difference. We generate anddisseminate information through meetings,publications, and an on-line presence; pro-vide training and technical assistance; offerstrategic advice on programmatic andoperational issues; and conduct studies ofthe field.

As the professional home for health grant-makers, GIH looks at health issuesthrough a philanthropic lens, sorting outwhat works for health funders of differentmissions, sizes, and approaches to grant-making. We take on the operational issueswith which many funders struggle (such asgovernance, communications, evaluation,and relationships with grantees) in waysthat are meaningful to those in the healthfield.

Expertise on Health Issues

GIH’s Resource Center on HealthPhilanthropy maintains descriptive dataabout foundations and corporate givingprograms funding in health and theirgrants and initiatives, and synthesizeslessons learned from their work. The

Resource Center’s database is available on-line on a password-protected basis to GIHFunding Partners (health grantmakingorganizations that provide annual financialsupport to the organization). The databasecontains information on thousands ofgrants and initiatives made by more than300 foundations and corporate giving pro-grams. It can be searched by organizationalcharacteristics (such as tax-exempt status,geographic focus, or assets); health pro-gramming areas (such as access, healthpromotion, mental health, and quality);targeted populations; and type of funding(such as direct service delivery, research,capacity building, or advocacy).

Advice on FoundationOperations

GIH also focuses on operational issuesconfronting health grantmakers throughthe work of its Support Center for HealthFoundations. We advise foundations justgetting started (including dozens of foun-dations formed as a result of theconversion of nonprofit hospitals andhealth systems) as well as more establishedorganizations. The Support Center’s activi-ties include:

• The Art & Science of HealthGrantmaking, an annual two-day meet-ing offering introductory and advancedcourses on board development, grant-making, evaluation, communications,and finance and investments;

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• sessions focusing on operational issues atthe GIH Annual Meeting on HealthPhilanthropy;

• individualized technical assistance forhealth funders; and

• a frequently asked questions feature onthe GIH Web site.

Connecting Health Funders

GIH creates opportunities to connect col-leagues to one another and with those inother fields whose work has importantimplications for health. GIH meetings,including the Annual Meeting on HealthPhilanthropy, the Fall Forum (when wefocus on policy issues), and IssueDialogues (intensive one-day meetings ona single health topic) are designed forhealth funders to learn more about theircolleagues’ work; talk openly about sharedissues; and tap into the knowledge ofexperts from research, policy, and practice.Our audioconference series allows smallergroups of grantmakers working on issuesof mutual interest, such as access to care,overweight and obesity, racial and ethnicdisparities, patient safety, or public policy,to meet with colleagues regularly withouthaving to leave their offices.

Fostering Partnerships

The many determinants of health statusand the complexity of communities andhealth care delivery systems temper healthgrantmakers’ expectations about going it

alone. Collaboration with others is essen-tial to lasting health improvements.Although successful collaborations cannotbe forced, GIH works to facilitate thoserelationships where we see mutual interest.We bring together national funders withthose working at the state and local levels,link with other affinity groups within phil-anthropy, and help connect grantmakers toorganizations that can help further theirgoals.

GIH places a high priority on bridging theworlds of health philanthropy and healthpolicy. Our policy portfolio includesefforts to help grantmakers understand theimportance of public policy to their workand the roles they can play in informingand shaping policy. We also work to helppolicymakers become more aware of thecontributions made by health philan-thropy. When there is synergy, we seek tostrengthen collaborative relationshipsbetween philanthropy and government.GIH has established cooperative relation-ships, for example, with a number offederal agencies, including the Agency forHealthcare Research and Quality and theCenters for Disease Control andPrevention.

Educating and Informing theField

An aggressive publications effort helpsGIH reach many grantmakers and provideresources that are available when fundersneed them. Our products include both in-depth reports and quick reads. Issue Briefs

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delve into a single health topic, providingthe most recent data, sketching out oppor-tunities for funders, and offering examplesof how grantmakers are putting ideas intoaction. The GIH Bulletin, a newsletterpublished 22 times each year, keeps fun-ders up to date on new grants, studies, andpeople. GIH’s Web site, www.gih.org, is aone-stop information resource for healthgrantmakers and those interested in thefield. The site includes all of GIH’s publi-cations, the Resource Center database(available only to GIH Funding Partners),and the Support Center’s frequently askedquestions. Key health issue pages on access,aging, children/youth, disparities, healthpromotion, mental health, public health,and quality provide grantmakers withquick access to new studies, GIH publica-tions, information on audioconferences,and the work of their peers.

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viii S E L L I N G H E A L T H Y L I F E S T Y L E S

GIH is committed to promoting diversityand cultural competency in its program-ming, personnel and employmentpractices, and governance. It views diversityas a fundamental element of social justiceand integral to its mission of helpinggrantmakers improve the nation’s health.Diverse voices and viewpoints deepen ourunderstanding of differences in health outcomes and health care delivery, and

strengthen our ability to fashion just solutions. GIH uses the term, diversity,broadly to encompass differences in theattributes of both individuals (such asrace, ethnicity, age, gender, sexual orienta-tion, physical ability, religion, andsocioeconomic status) and organizations(foundations and giving programs of differing sizes, missions, geographic loca-tions, and approaches to grantmaking).

Diversity Statement

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

The Legal Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Motivating Factors for Supporting Advocacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

Making the Case: Challenges and Solutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Tools and Strategies for Effective Advocacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Evaluating Policy and Advocacy Grants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

Lessons Learned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

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Table of Contents

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G R A N T M A K E R S I N H E A L T H 1

Introduction

The voices and priorities of the most vul-nerable populations are often left out ofpublic debates and policy decisions.Advocacy involves changing public opinion and community, institutional, orgovernment policies to include these voic-es. Health funders with an eye on broader,systemic change are increasingly consider-ing advocacy strategies as a means toexpand health care access, eliminate racialand ethnic disparities, tackle rising obesityrates, and take on other tough issues. Butsupporting advocacy is not without itschallenges. Even experienced grantmakerswith a dedicated history of funding healthadvocacy contemplate the efficacy of theirstrategies and continuously ponder the elements of a successful grantmaking portfolio in health advocacy. Moreover,due to the unpredictable nature of fundingfor advocacy organizations and the constant concern for sustainability, grantmakers are always searching for waysto connect with their colleagues, learnfrom one another, and share ideas.

Public Policy and Advocacy

In the health care arena, public policydecisions determine who is eligible forpublic insurance programs; how muchfunding is available for public health pro-grams; which health care services areprovided (such as immunizations, languageservices, or prenatal care); and other fun-damental choices. Sound public policiesdepend on several factors, including theavailability of reliable information andobjective analysis, the input of thosedirectly affected by these policies, andinformed decisionmakers. Unfortunately,

these factors are not always in place whenhealth policy decisions are made, decisionswhich have a significant impact on thedesign of health care delivery, the alloca-tion of resources, and priority setting forhealth programs.

Health advocacy focuses on ensuring thatdiverse viewpoints are considered whenmaking decisions that shape the healthcare system. Advocates representing insur-ance companies, hospitals, purchasers, andproviders devote considerable resources topush for policies that benefit their inter-ests. While underserved populations maynot have the same level of resources and,in some cases, the know-how to advocatefor their own needs, there are proven mod-els for engaging and mobilizing vulnerablepopulations, strengthening and includingtheir voices in the political process, andultimately producing better informed poli-cy decisions. Grantmakers interested inhealth advocacy are working to ensure thatthe appropriate factors are in place whendecisions are made and that public policiesare focused on providing quality, afford-able, and equitable health care for all.

There are various ways to influence publicpolicy. Advocacy is one of them. Viewingpublic policy work as a continuum mayhelp grantmakers recognize opportunitiesfor supporting broad policy change andhow activities they are currently funding fit into a broader agenda (Figure 1). Thecontinuum can be used as a tool for foun-dations interested in funding public policy.Which components a foundation decidesto fund depends on several factors, includ-ing the foundation’s mission, vision, andtheory of change; the needs and capacityof the community; and the fit between thefoundation’s and community’s goals. While

2 F U N D I N G H E A L T H A D V O C A C Y

Figure 1. Public Policy Continuum: Idea to Implementation

Problem Definition/ Advancing Solution/ Solution Development Advocacy Implementation

GOAL To clearly articulate problem andsolution

Research and analysis

Polling

Issue framing and messaging

Convenings

Stakeholder engagement

Solutions identification

To build political will to take action

Community organizing

Polling

Message refinement

Public education and informationcampaigns

Advocacy capacity of diversestakeholders

Coalition building

Media advocacy

Educational materials for opinionleaders and policymakers

To foster effective implementation

Monitoring

Lobbying

Litigation

Public education

Evaluation

COMPONENTSOF POLICYCHANGE

Source: Adapted from Holton, Ruth, The California Wellness Foundation, remarks at Grantmakers In Health Issue Dialogue, Funding Health Advocacy, November 3, 2004.

some foundations, such as The CaliforniaWellness Foundation, fund all activitieslisted in the continuum, others maychoose to fund only one or two and stillmake a significant impact (Holton 2004).

The LegalFramework

To take advantage of the full range of per-missible options to support advocacy,foundations need to first understand thefederal tax law governing advocacy, admin-istered by the Internal Revenue Service(IRS). While breaking the rules, even inad-vertently, can lead to penalties such asexpensive fines or even the loss of nonprof-

it status, there is a great deal more leewayfor foundations to engage in advocacy andpolicy-related activities than many mayrealize. This flexibility includes fundinggrantees in support of advocacy and policychange, as well as activities that grantmak-ers can undertake to advance the missionof their own foundations.

Restrictions on foundation support ofadvocacy activities apply only to lobbying.Therefore, it is important to distinguishbetween advocacy and lobbying, which areoften incorrectly used interchangeably.Advocacy is much broader than lobbying;while lobbying is part of an advocacy strat-egy, advocacy does not always includelobbying. And even with these restrictionson lobbying, foundations can fund a broadrange of activities without fear of losing


their nonprofit status. The following sec-tions are intended to provide moreinformation on the basic rules for fundinglobbying, though they are not meant to be a substitute for sound legal advice inspecific situations.1

Electioneering

Partisan electoral activities, or attempts toinfluence elections, are prohibited for all501(c)(3) organizations, including privatefoundations. Also known as electioneering,these activities include any involvement insupport for or opposition to a candidatefor public office (as opposed to ballot initiatives). Activities, however, that mayincidentally influence the outcome of elections are permitted if carried out in astrictly nonpartisan manner. Examples ofpermissible activities include nonpartisanget-out-the-vote drives or candidateforums designed to inform the publicabout election issues (Asher 1995).

Lobbying

In a survey of 1,700 nonprofit organiza-tions and interviews with nonprofitleaders, conducted as part of theStrengthening Nonprofit Advocacy project,respondents felt that foundations do notsupport lobbying undertaken by nonprofitorganizations, and that they unnecessarilyplace restrictions on using grant funds forlobbying purposes (The Aspen Institute2004). This is partially a result of confu-sion among foundations about what canbe done with their funds and the restric-tions they may unnecessarily place on theirgrantees to use foundation funding forlobbying.

While most private foundations may notlobby (with a few exceptions), the law pro-vides some latitude for foundation supportof lobbying, and even includes a numberof exceptions permitting activities founda-tions can undertake to influence policythat are described later in this section.

Lobbying is defined as an attempt to influ-ence specific legislation, which includesboth legislation that has already beenintroduced in a legislative body and a specific legislative proposal that the organization either supports or opposes.There are two types of lobbying:

• Direct lobbying includes attempts toinfluence legislation by communicatingwith legislators, their staffs, certain gov-ernment employees, and the generalpublic regarding referenda and other bal-lot measures. To constitute lobbying, acommunication must refer to andexpress a view on specific legislation.

• Grassroots lobbying refers to communi-cations that attempt to influencelegislation by urging the general publicto influence legislators. To constitutelobbying, a communication generallymust refer to specific legislation; reflect a view on the legislation; and include acall to action, which is defined as a state-ment directing readers to contact theirlegislator (Asher 1995).

There are two clear prohibitions withregard to foundations and lobbying. First,private foundations may not engage ineither direct or grassroots lobbying.Foundations may, however, lobby on theirown behalf with regard to legislation thataffects their powers, duties, tax-exempt sta-

1 This Issue Brief focuses primarily on private foundations and grantmaking public charities.


This grant is for the grantee’s generalsupport. No funds are earmarked forthe purposes of influencing legisla-tion, and the grantee cannot expendany part of the grant in any way thatviolates its tax-exempt status (Asher1995 and Holton 2002).

Specific Project GrantsUnder the tax law, private foundations arepermitted to provide project grants to nonprofit organizations designated as public charities, as long as funding is notearmarked for lobbying and the grant (plus other grants by the foundation forthe same project that year) is less than theproject’s budgeted nonlobbying expensesfor that year. As documentation, the foun-dation may rely on a grantee’s budget orsigned statement of lobbying intentionsunless the foundation has a reason to question its accuracy. For example:

A foundation makes one $10,000grant in a year toward a specific project. The grantee’s total projectbudget is $50,000, and $20,000 isbudgeted for lobbying expenses. Ifthe grant is not earmarked for lobby-ing, it is permissible because theproject’s budget for nonlobbyingactivities is $30,000, which exceedsthe grant’s amount of $10,000(Asher 1995).

For multiyear project grants, a foundationmay either measure the grantee’s budgetsfor each year covered by the grant againstthe actual grant amount paid in each year

tus, and the deductibility of contributions.For example, proposed legislation tochange the payout provisions for privatefoundations would fall under this exception. Second, foundations may notearmark grants for lobbying without mak-ing a taxable expenditure.2 If paymentspaid or incurred by a private foundationare earmarked for lobbying, taxes areimposed (Levine 2004).3

Foundations have much more flexibility infunding lobbying than they may realize.While funds may not be specifically ear-marked for lobbying activities, the federaltax code does contain safe harbors thatallow foundations to support lobbying bynonprofit organizations, as long as certainconditions are met. The following exam-ples describe ways foundations mayprovide funding through both generaloperating support and specific projectgrants.

General Support GrantsGeneral support grants offer the greatestflexibility for nonprofit organizations toengage in advocacy and, at the same time,protect a foundation from the limitationson funding lobbying activities. A grant forcore operating support is not a taxableexpenditure, even if the funding is subse-quently used for lobbying. Moreover,grantees are not required to submit projec-tions of their lobbying expenses, freeingthe grantee from the burden of segregatingits expenses related to lobbying from itsoverall budget. To protect the grantorfoundation, it is key to include language in the grant agreement letter, such as:

2 For the purposes of this Issue Brief, a taxable expenditure includes grants that are earmarked for lobbying.3 There is a 10 percent tax on each taxable expenditure and a 100 percent tax if the expenditure is not corrected within the taxable period.

The taxable period begins with the date on which the taxable expenditure occurs and ends on the earlier of the date of mailing of a notice of

deficiency or the date on which the tax is assessed. In addition, a tax equal to 2.5 percent of the taxable expenditure is imposed on the

foundation managers who agreed to the making of the expenditure (not to exceed $5,000), and a tax equal to 50 percent of the amount of

the taxable expenditure is imposed if the foundation manager refuses to agree to part of all of the correction (not to exceed $10,000).


or the grant’s total amount evenly dividedover the years it covers. For example:

A foundation makes a $100,000grant over two years toward a specificproject, transmitting $30,000 in thefirst year and $70,000 in the second.To demonstrate that no portion ofthe grant is earmarked for lobbying,the foundation may measure againstthe grantee’s budgeted nonlobbyingexpenses for the project for each yeareither (a) $30,000 in the first yearand $70,000 in the second year, or(b) $50,000 (or one-half of the totalgrant) in each year (Asher 1995).

Rules Differ by Tax Status of theGrantmaking OrganizationThe law applies differently depending onthe grantmaking organization’s tax status.The rules governing lobbying describedpreviously, apply primarily to private foundations. Public foundations and public charities are not subject to the samerestrictions imposed on private foundationsand have greater flexibility to support andengage in advocacy. Social welfare organi-zations, exempt under Section 501(c)(4) of the tax code, do not have a limit on the amount of lobbying in which they canengage.4 Public foundations, which includemost community foundations, are permit-ted to earmark grants for lobbyingpurposes and may even lobby themselves,as long as that does not become a substan-tial part of their activities.

The IRS rules limit the amount of lobby-ing activities of 501(c)(3) public charities,but these organizations may choose one oftwo standards by which their compliancewill be measured: the insubstantial parttest or the 501(h) expenditure test.5

Organizations that choose to be covered by the 501(h) expenditure test are referredto as electing charities, while those thatremain subject to the insubstantial part test are called nonelecting charities.

Nonelecting charities opt to comply viathe insubstantial part test, which requiresthat “no substantial part of a charity’sactivities consist of carrying on propagandaor otherwise attempting to influence legis-lation.” If a charity exceeds this standard ina single year, it risks losing its exemptionaltogether. Some caution should be exer-cised with this choice, especially since theIRS has not defined the terms, “lobbying”and “substantial.” When the IRS reviewsthe lobbying activities of nonelecting char-ities, it does not limit itself to the amountsspent on lobbying. Rather, it examines ahost of other factors, such as the organiza-tion’s goals and success in achieving them,as well as the amount of time and energydevoted to legislative matters (Alliance forJustice 2004a).

Under section 501(h) of the InternalRevenue Code, public charities can elect tomeasure their lobbying by an expendituretest, which allows greater freedom forengaging in lobbying activities. The 501(h)expenditure test sets specific dollar limits,calculated as a percentage of annual

4 Generally, these organizations are advocacy groups such as National Association for the Advancement of Colored People or the American

Association of Retired Persons. But there are also a number of foundations that are classified as social welfare organizations that were devel-

oped out of the conversion of nonprofit health care organizations. Some retain their 501(c)(4) status for tax reasons, but may also adopt the

501(c)(3) provisions that limit lobbying activities as part of their bylaws.5 Private foundations cannot make the 501(h) election, but can financially support public charities that do.


may convene interested parties (includ-ing legislators, executive officials, andtheir staffs) around issues of concern, aslong as the discussions focus on topicsother than the merits of specific legisla-tion.

• conduct and release nonpartisan analyses, studies, or research. In commu-nicating such research, the foundation orits grantee may even take a position onspecific legislation, as long as all the factsrelated to the issue are presented fairly,and it is possible for the reader to forman independent opinion or conclusion.The research must be widely disseminat-ed. For example, a report on access tohealth care for low-income childrenmight conclude with a recommendationfor increased public funding for childhealth insurance programs.

• respond to written requests for technicaladvice or testify at legislative hearings.When testifying before legislative bodies,unlike presenting nonpartisan analysis,foundation representatives are permittedto support or oppose specific legislation(Edie 1991). The written request mustcome from a legislative body and not anindividual legislator (Asher 1995).

Second, a staff or board member of afoundation may also meet with legislators,exercising the right as an individual con-stituent, to participate in the policyprocess. It is important, however, to sepa-rate this activity from work conducted onbehalf of the foundation. For instance,foundation representatives may set up ameeting with their legislators on their owntime, with no mention of their foundationaffiliation (Alliance for Justice 2004b).

exempt purpose expenditures. The amountallowed for lobbying is determined upfront, and the IRS clearly defines lobbyingcommunications and exceptions to lobby-ing. Electing organizations typically haveless chance of losing their tax exemptionthan nonelecting organizations, becausethe IRS considers the electing organiza-tion’s lobbying and grassroots expendituresas a moving average over a four-year period and can revoke the organization’sexemption only if it exceeds either limit by50 percent. Depending on the size of theirbudget, electing public charities can makeexpenditures for lobbying up to 20 percentof their budgets (Alliance for Justice2004a).

Permissible Activities Underthe Tax Law

The IRS restrictions on lobbying by non-profit organizations affect only a smallportion of the advocacy-related activitiesthat foundations can undertake. First,there are several important exceptions tothe law regarding lobbying that open upopportunities for foundations to shareinformation on policy issues with policy-makers and the public. The followingexceptions provide a framework for theactivities that foundations can engage ineither directly or indirectly by providinggrants to other organizations.

Foundations can:

• conduct examinations and discussions ofbroad social and economic problems —even if these involve communicatingwith legislators or their staff. The key isnot to discuss specific legislation orinclude communication that contains acall to action. For example, foundations


Finally, foundations may engage in otheradvocacy activities that fall outside of theIRS definition of lobbying. For example:

• Most communications to the publicabout a general issue of concern are per-mitted, as long as there is no reference tospecific legislation, no position taken onthe legislation, or no call to action, andthe communication does not take placewithin two weeks prior to a legislativevote. For example, conducting publiceducation campaigns through radio ortelevision advertisements or using directmail and other forms of public commu-nication about specific health policyissues are not considered lobbying whenthe objective is to educate the publicrather than influence legislation, and alegislative vote on the topic is not imminent.

• Actions designed to address the imple-mentation of existing laws, such as thepromulgation of regulations, by adminis-trative bodies are also permissible. Theseencompass activities that range fromfoundation-initiated projects to formalcollaboration with government toachieve shared goals (Edie 1991).

Motivating Factorsfor SupportingAdvocacy

Once foundations understand the legalframework for funding advocacy, the nextstep is for grantmakers to think about howadvocacy fits into the foundation’s work

and can be used as a strategy for advancingits mission and goals. As with most strate-gies, one size does not fit all. Everyfoundation’s approach to advocacy is dif-ferent and is rooted in different ideologiesand motivations. There are, however, somecommon themes that have emerged fromfoundations engaged in this work, includ-ing why foundations decide to fundadvocacy and how they go about fitting it into their grantmaking portfolios.

Increased Interest in HealthPolicy

Many foundations have increased fundingfor health policy activities in the pastdecade, according to a study by theFoundation Center. Total grant dollars targeting health policy activities more thantripled from 1995 to 2002, from justunder $100 million to nearly $360 mil-lion. Funding for health policy activitiesalso made up a larger share of overall funding, accounting for 12.5 percent ofthe health grant dollars in 2002 versus 9 percent in 1995 (Lawrence 2004).

A number of factors have come together topush foundations in this direction. Theseinclude shrinking public budgets andresulting cuts to public health services,declining foundation assets, and the beliefthat investing in health policy could con-tribute to more sustainable public fundingstreams. Grantmakers with a longtimeinterest in improving the health of individuals and communities are utilizingadvocacy and policy activities to comple-ment grants for direct services, realizingthe enormous potential for influencing systemic change and benefiting a greaternumber of people.

“There is hope when you

fund advocacy, because

that’s how you manage to

get the change that you

want. If you don’t fund

advocacy, you’re not going

to get the change that you

want. It’s that simple.”

RUTH HOLTON,

THE CALIFORNIA

WELLNESS FOUNDATION


A Compatible Theory ofChange

As with any new initiative or funding pri-ority, grantmakers often come to severalkey junctures before moving forward. Eachfoundation’s experience and decisionmak-ing process is different, but some of thekey questions grantmakers consider before committing to funding advocacy are:

• How does advocacy support our missionand fit in with our other funding priorities?

• How will this affect our other work,namely grants for direct services and project-specific grants?

• What is the foundation’s role in buildinga community of advocates?

• How will our foundation be viewed byour grantees, the general public, policymakers, key opinion leaders, andother stakeholders, such as donors (particularly for those foundations whoseendowments rely on a pool of donors)?

In 2003, The California Endowment(TCE), the state’s largest health philan-thropy, strengthened its commitment tosupporting advocacy and policy change.Although the foundation has supportedgrantee efforts in this area since its incep-tion in 1996, declining revenues for thepublic and private sectors brought a fullappreciation for the importance of sup-porting long-term change. Thefoundation’s board and staff recognizedthat no matter how many investmentswere made in community clinics, newhealth programs, or community-basedpartnerships, sustainable solutions wouldonly come about through systemic change.

In recent years, nonprofit organizations incommunities nationwide have been feelingthe pinch of budget cuts at the federal,state, and local levels. The existence oflarge budget deficits at all levels of govern-ment set the context for health policydecisions on public health programs, many of which have a direct impact on the health of individuals and communities.Various health programs are in jeopardy ofexperiencing debilitating cuts. Althoughplanning for long-term sustainability haslong been on the minds of health funders,these challenging economic times have ledgrantmakers, more than ever, to considerstrategies that will both protect public programs in the short term and fostermore sustainable, equitable policies overthe long term.

Challenging economic conditions affectfoundation budgets as well. The stockmarket downturn forced foundationboards and staffs to carefully examine theirorganizations’ resources and fully assess theimpact of their investments. As a result,grantmakers are looking for strategicopportunities to make grants that may cre-ate and sustain increased funding streamsfor the health issues they care about.

One cannot ignore the vital role govern-ment plays in funding necessary healthservices and programs. Philanthropic fund-ing for health, though valuable andindispensable to many communities, ismarginal in absolute dollars comparedwith the public share. And while founda-tions do not have the resources to changesocial conditions one grant at a time,grantmakers do have the potential tounlock larger pots of money that can leadto sustainable resources to meet importanthealth needs.

“It is incumbent upon

grantmakers to have a firm

grasp of and trust their

theory of change. Our

foundation funded the

regional networks that

support community clinics

in our state, which we

believe will lead to more

stable funding of

community clinics, which

we believe will lead to

improved access and better

health. Because of this circle

of thinking, we hang in

there . . . for the long haul.”

LAURA HOGAN,

THE CALIFORNIA

ENDOWMENT


The foundation’s strategy for funding pub-lic policy and advocacy focuses onsupporting communities, as key agents ofchange, to work towards making thehealth care system more responsive to theneeds of all Californians; assisting policy-makers in gathering relevant data andinformation, analyzing research findings,and identifying policy options; and sup-porting advocacy efforts that can lead toimproved access to quality health care forall Californians (The CaliforniaEndowment 2003).

The Connecticut Health Foundation, astatewide foundation dedicated to improv-ing the health of the people ofConnecticut through systemic change andprogram innovation, funds in three priori-ty areas: oral health, children’s mentalhealth, and racial and ethnic health dispar-ities. Since its inception in 1999, thefoundation has focused its resources onpolicy research, technical assistance, andgrantmaking. Goals and objectives for eachof these priority areas take into considera-tion government efforts, opportunities forimpact, foundation resources, and mea-surement strategies available. Eachobjective is approached through a varietyof strategies, including community grants,advocacy, research, communications, pro-fessional training, and capacity building.

At the Missouri Foundation for Health(MFH), a statewide foundation formed in2000 after the sale of Blue Cross BlueShield of Missouri, the board of directorsestablished the policy group to comple-ment the foundation’s grantmaking effortsand address health issues from a systemicperspective. The foundation’s policy group

supports the work of its board and staff, as well as community members and state legislators, by providing timely research on health-related issues of significance toMissouri. The foundation’s policy agendaincludes universal coverage, trauma services, community-based prevention,children’s health, and health disparities.

In 2004, MFH announced the availabilityof general support grants to strengthen thestate’s nonprofit advocacy agencies. Underthis request for proposals, eligible organiza-tions included nonprofit agencies activelyinvolved in advocacy work on behalf ofMissouri residents. The impetus for thisfunding came from the knowledge that,given the inherently unpredictable natureof factors that influence the politicalprocess, advocacy organizations need thecapacity and financial flexibility to respondto newly emerging policy issues in a timelymanner.

Making the Case:Challenges andSolutions

Initiating funding in health advocacy andmaking the case for continued funding inthis area of work is not without its chal-lenges. Grantmakers have identified severalobstacles, including debunking the myththat funding advocacy is not legal, convincing board members to supportadvocacy, and explaining to skeptics thatthe journey can be just as valuable as thefinal outcome.

1 0 F U N D I N G H E A L T H A D V O C A C Y

The Law Is On Your Side

One reason foundations cite for theirreluctance to initiate funding in this area isa lack of understanding regarding the lawsgoverning foundation support for advoca-cy. Despite the many resources available,this sentiment is persistent among staffs,boards, and attorneys advising funders. But this barrier can be overcome. At theNew Hampshire Charitable Foundation,for example, staff prepared a memo for the board clarifying the federal law, so thatmembers would be clear what was (andwas not) within legal limits. Once boardmembers fully understood, the foundationwas able to move forward in funding advo-cacy (Aron 2004). Taking advantage of thewealth of information available on the lawsgoverning advocacy and lobbying, as wellas changing attitudes on the importance of advocacy, are the first steps to initiatingfunding in this area and garnering support.

Working with the Board

For foundations moving into advocacyfunding, an important step is workingwith board members to help them under-stand and embrace goals for policy andadvocacy. Foundation staff and board leaders should look for opportunities toeducate current board members, as well as recruit new board members that willendorse the foundation’s work in this area.

Foundation boards typically comprise busi-ness leaders, affluent community members,and others who may not be familiar orcomfortable with this work. This composi-tion can be a barrier to funding policy andadvocacy. While it may be easy to makethe case for funding the provision of healthcare insurance for children or a communi-ty health center, some board members may

be reluctant to fund initiatives that couldresult in increased taxes or that put thefoundation at the forefront of controversialpolicy discussions.

Foundations that rotate board membersand bring in individuals on a defined basisfor open seats have an opportunity toinfuse fresh perspectives into the organiza-tion, as well as influence the outlook ofexisting board members. Individuals whohave intimate experiences with communityneeds and experience as advocates are morelikely to support policy and advocacyactivities. Including even one or two boardmembers with this background and per-spective may change the shape of theentire board and increase the likelihood forengaging in policy and advocacy (Lewis2004). Additionally, the orientationprocess for new board members is anotheropportunity to express the culture anddirection of the organization to ensure thatincoming board members understand thefoundation’s approach to grantmaking(Canty 2004).

A number of strategies for working withboard members can lead them in a direction to support work on policy and advocacy. For example:

• The Health Foundation of CentralMassachusetts, Inc. made a major investment in, and ultimately lost, a fluoridation campaign. Rather than getdiscouraged, staff used this experience asan opportunity to reexamine how itsboard prepared for future advocacyefforts. The foundation hired an experi-enced policy advocate to train and coachboard members on ins-and-outs of funding advocacy, and address their questions and concerns (Johnson 2004).

“A myth has taken hold that

because foundations cannot

lobby, they cannot fund

organizations that lobby.

It’s not true!”

NAN ARON,

ALLIANCE FOR JUSTICE

“Perhaps as foundations we

ought to do what we tell our

grantees to do. That is, if we

want our foundation to go

in a particular direction, we

not only hire the leadership

to take us there, but we

begin to shape our board to

go there as well.”

DIANE LEWIS,

CONSUMER HEALTH

FOUNDATION

G R A N T M A K E R S I N H E A L T H 1 1

• The Connecticut Health Foundation hasestablished a policy committee on itsboard to take control of policy internallyand be responsible for addressing politi-cal issues. In doing so, the foundation’sboard and staff fully understand that thisincludes a fair share of wins, as well aslosses. While it did have success immedi-ately, the board recognizes that it mayhave to someday be at the forefront ofcontroversial issues or be willing toaccept policy failures. The foundation isalso reaching out to other communityopinion leaders, particularly those in thebusiness and labor communities, to build

a stronger collaborative effort aroundhealth policy issues (Canty 2004).

Some foundations invite board membersto affinity group meetings and use this asan opportunity to introduce them to issuesthey may not be exposed to in their everyday lives. The Consumer HealthFoundation devotes time at the followingboard meeting to think about what waslearned or to have a policy discussion.Board members discuss the key take-awaylessons and then reflect on how thoserelate to the foundation’s work (O’Bryon2004).

VALUING THE JOURNEY

A concern that emerges when foundations begin to fund policy and advocacy is thehesitancy to support and pursue policies that may sound worthwhile, but that havenot yet been proven to be effective. Take, for example, the issue of banning soda inschools. Advocates fighting the obesity epidemic have been instrumental in putting astop to soda contracts in school districts. Skeptics, on the other hand, questionwhether this strategy will have a significant impact on the individual weight ofschoolchildren, and whether this is a fight worth fighting.

The steps needed to achieve an ultimate policy goal can be just as valuable as thefinal outcome, whether it is improved health outcomes or a policy change. In mostcases, there is not a single best solution. But pursuing a specific strategy or focusingon one aspect of a broader issue can create public understanding of the entire issue.Calling attention to soda in schools has contributed to public recognition of the larg-er issue of childhood obesity and the role of school environments in promotinghealthy behaviors. Additionally, an underestimated benefit of engaging in policychange is relationship building among different stakeholders. This issue broughttogether public health officials, school administrators, and parents—groups with acommon connection, but that are hardly in contact with one another. It is oftenthese relationships that make larger and lasting reform possible (Sherry 2004).

Finally, advocates recognize that removing soda from schools may not have a defin-able impact on individual weight of children in those schools. Advocates argue,however, that this policy change has no adverse health impact and more important-ly, that it furthers a larger debate within the public health community, the educationcommunity, and the broader community. Banning soda from schools contributes toa broader public health agenda and is one step toward reforming the school envi-ronment to support healthy behaviors. It is often a collection of small victories thatmakes real change possible, so perhaps the fight is one worth fighting (Harvey2004).


makers are supporting and contributing toefforts to collect and disseminate healthdata, analyze policy issues, provide a forumfor the discussion of public policy issues,and educate policymakers.

Arming Advocates and Policymakerswith DataFoundations play an important role insupporting the collection of accurate andreliable data on issues of concern to advo-cates and policymakers. The Annie E.Casey Foundation has funded KIDSCOUNT, a national and state-by-stateeffort to track the status of children in theUnited States by 10 specific measures.6

By providing policymakers and the publicwith benchmarks of child well-being,KIDS COUNT seeks to enrich local, state,and national discussions concerning waysto secure better futures for all children.The national KIDS COUNT data book,which provides information on the educa-tional, social, economic, and physicalwell-being of children, is produced annual-ly. At the state level, the foundation fundsa nationwide network of state-based KIDSCOUNT projects that present a moredetailed picture of the condition of chil-dren in specific communities. Both thenational and state-level reports havereceived extensive media coverage andserved as springboards for several editorialopinions on improving the lives of chil-dren. In many states, KIDS COUNTpublications have been the catalyst forpublic and private initiatives to improvechildren’s lives.

Tools and Strategiesfor EffectiveAdvocacy

As mentioned previously, advocacy ismuch broader than lobbying and includesseveral different components, most ofwhich are not subject to IRS regulations.These include those activities alreadydescribed in this Issue Brief as well asnumerous others that contribute to broadpolicy change. The following sectionsdescribe how foundations are supportingunbiased research and policy analysis,increasing public understanding of healthpolicy issues, engaging communities to foster consumer empowerment, buildingthe capacity of organizations to engage inadvocacy, funding specific advocacy campaigns, fostering collaboration andcoalition building among advocacy communities and others, and supportingsabbaticals for nonprofit leaders.Grantmakers are employing these varioustools and strategies in their efforts to support advocacy and learning which ones work best for their communities.

Research and Policy Analysis

Research and policy analysis are importanttools for health advocates and lay the foundation for engaging in any healthissue. Grantmaker support in this area provides an opportunity to place unbiased,nonpartisan information into the hands ofadvocates and policymakers. Health grant-

6 Currently, KIDS COUNT measures include percentage of low birth-weight babies; infant mortality rate; child death rate; rate of teen deaths

by accident, homicide, and suicide; teen birth rate; juvenile violent crime arrest rate; percentage of teens who are high school dropouts; per-

centage of teens not attending school and not working; percentage of children in poverty; and percentage of families with children headed

by a single parent.


For general health-related data, The HenryJ. Kaiser Family Foundation sponsorsStatehealthfacts.org, an on-line resourcedesigned to provide free, up-to-date, andeasy-to-use health data on all 50 states.The Web site provides data on more than400 key health and health policy issuescollected from a variety of public and pri-vate sources, including the foundation’sown reports, data from public Web sites,and information purchased from privateorganizations.

Some grantmakers fund efforts to providespecific information to help advocates andpolicymakers make better informed healthpolicy decisions. For example, TheCalifornia Endowment, The CaliforniaWellness Foundation, Kaiser Permanente,and The Robert Wood JohnsonFoundation have funded the CaliforniaCenter for Public Health Advocacy todevelop policy briefs that present data onthe health status of individuals by state legislative district (rather than by city orcounty), along with detailed informationand recommendations for addressing theseissues through specific state and local poli-cy reforms. The first series of briefs focusedon childhood fitness, obesity, and diabetes,some of California’s most urgent publichealth challenges. These data and information on childhood obesity ratescontributed to the passage of a landmarkbill that established nutrition standards for food and beverages sold in Californiaelementary schools (TWCF 2004a).

Grantmakers are also using data collectedat the local level as a tool for promotingpolicy change. The Rapides Foundation

commissioned a community health assess-ment to build on and update an earlierassessment that collected health-specificdata and identified community needs. The foundation, whose service areaincludes nine parishes in central Louisiana,is one of the largest grantmaking organiza-tions per capita in the southeastern UnitedStates. The assessment drew upon datafrom three distinct sources: a communityhealth survey, including randomized tele-phone interviews conducted to assess thehealth and behaviors of community mem-bers; existing public health data, includingstatewide and nationwide risk assessmentsthat were used to complement the surveyprocess and provide a benchmark for thesurvey data; and community health panels,including focus groups that consisted ofcommunity leaders and representativesfrom the different communities. The foundation recognizes that improving the overall health of individuals requiresinvestments in both new and existing organizational structures within a commu-nity. Therefore, it makes these dataavailable to individuals, nonprofit organi-zations, government officials, and businessleaders so that these stakeholders are betterable to work together and target improve-ments in the standard of living for allcommunity members.

Funding Analysis of Policy IssuesIn addition to data collection, healthgrantmakers are funding health policyanalysis activities that shed light on impor-tant health issues. At the national level,both The Henry J. Kaiser FamilyFoundation and The CommonwealthFund serve as credible sources of informa-


• The Connecticut Health Foundation andUniversal Health Care Foundation ofConnecticut (formerly the AnthemFoundation of Connecticut) jointlyfunded a research team at GeorgetownUniversity to analyze the impact of theBush Administration’s Medicaid reformproposals on the state of Connecticut.

• The Healthcare Georgia Foundation has provided significant funding to theWomen’s Policy Education Fund inAtlanta to create a centralized source ofWeb-based and printed material trackinghealth policy in Georgia and encourageits use by consumer-focused organiza-tions and other key stakeholders. Thefoundation has also provided funding tohelp establish the Institute for HealthPolicy at Morehouse School ofMedicine’s National Center for PrimaryCare, directed by former SurgeonGeneral David Satcher. The grant isfunding research on primary care, pre-vention, and mental health services forminority and underserved communitiesin Georgia. The institute will focus onthe following questions: state and federalpolicies that would encourage health professionals to practice primary care inunderserved communities and promotelong-term retention, ways that Georgiacould develop a cohesive and compre-hensive primary care safety net thatassures access to high-quality care for allGeorgians, and the impact of existinghealth laws and policies and proposedlegislation on clinical outcomes.

• The Endowment for Health funded amultiyear project of the New HampshireCenter for Public Policy Studies to iden-

tion on the Medicare and Medicaid pro-grams by analyzing program fundamentals,monitoring implementation issues, andweighing in on proposed reforms.

Both foundations provided analysis of keyhealth policy issues during the 2004 election season. In the weeks preceding the election, The Henry J. Kaiser FamilyFoundation issued several backgroundissue briefs on health care costs; Medicarecoverage and financing; the uninsured;women’s health policy; race, ethnicity, andhealth care; HIV/AIDS; medical liabilityreform; public opinion polls; prescriptiondrug costs; and side-by-side comparisonsof the presidential candidates’ views onMedicare, health insurance coverage forthe uninsured, women’s health policy,HIV/AIDS, and medical liability reform.

Similarly, The Commonwealth Fundauthored an analysis of both presidentialcandidates’ proposals to extend healthinsurance coverage, which each built onthe existing system of private and publichealth insurance in the United States,rather than fundamentally reforming thehealth care system. To help put the propos-als in perspective, the report, Health CareReform Returns to the National Agenda:2004 Presidential Candidates’ Proposals,included the latest versions of the Bushand Kerry programs, the numbers of uninsured each plan would cover, and the estimated costs of each.

While the national funders are often citedas primary sources of policy analysis, funders working at the state and local levels are also stepping into this role. Forexample:


tify and support public policy proposalsto reduce the percentage of NewHampshire’s population without healthinsurance. Specific components include astudy of how other states have addressedthis issue, a review of all pertinent federalinititives before the Congress, and ananalysis of financing options.

Providing a Forum for Discussion ofPublic Policy IssuesMany health funders are in the advanta-geous position of having the ear of diversemembers of the community, such as busi-ness leaders, policymakers, and grassrootsactivists. Exercising their role as convener,grantmakers are providing opportunitiesfor the discussion of public policy issues tohelp inform the public debate on impor-tant health topics. The Blue Cross BlueShield of Massachusetts Foundation, forexample, hosts a yearly summit to examineexpanding access to health care inMassachusetts. At its 2004 meeting, thefoundation released a report it commis-sioned, authored by the Urban Institute,that analyzed (for the first time) all of the medical care provided to uninsuredpatients by hospitals, community healthcenters, and physicians in the state. Thestudy concluded that if the uninsured inMassachusetts had health coverage, theannual cost of the additional medical carethey would receive would be between$374 million and $539 million; this wouldincrease the share of the state’s economydevoted to health care by less than one-third of one percentage point.Additionally, the authors noted thatexpanding coverage to the uninsured could result in as much as $1.2 billion to

$1.7 billion in economic and social bene-fits from improved health, which couldexceed the incremental medical costs ofexpanded coverage by a ratio of 3:1.

To bring attention to the critical issue ofracial and ethnic health disparities, TheCalifornia Endowment partnered with theCongressional Tri-Caucus (includingmembers of the Congressional BlackCaucus, the Congressional HispanicCaucus, and the Congressional AsianPacific American Caucus) to host Bridgingthe Health Divide: A Congressional Forumon Racial and Ethnic Health Disparities.This one-day meeting brought togethermore than 200 local community leaders,health providers, and representatives fromcommunity-based organizations for a first-ever forum to discuss why racial andethnic minorities have poorer health statusand higher death rates than the generalpopulation. The goals of the forum wereto:

• provide a call to action around the rec-ommendations offered in several reports,such as Unequal Treatment: ConfrontingRacial and Ethnic Disparities in HealthCare, published in 2002 by the Instituteof Medicine, and the National HealthcareDisparities Report, developed by the U.S.Department of Health and HumanServices;

• hear from community leaders about localefforts to address disparities, particularlybest practices and promising programs;and

• discuss ways to collectively accelerateprogress toward eliminating health disparities.


Educating PolicymakersA number of health grantmakers are working to educate policymakers aboutimportant health topics. According toEmmett Carson, president and CEO ofthe Minneapolis Foundation, “It is notenough for grantmakers to support the service delivery arm of a hardworking non-profit organization. We’ve got to recognizethat educating public policymakers is partof our responsibility as grantmakers andcrucial to our success” (Alliance for Justice2002). In an effort to provide Colorado’sstate legislators with opportunities to learnabout emerging health policy issues, RoseCommunity Foundation developed HotIssues in Health Care. Beginning with atwo-day briefing for new and returningColorado legislators in 2000, Hot Issues hasnow been expanded into a year-roundeffort that includes panel discussions,briefings, and “Red Hot” papers that pro-vide analysis of health issues and theirimpact in Colorado. This initiative pro-vides legislators, other appointed andelected policymakers, and their respectivestaffs with objective health policy informa-tion that is responsive to these leaders’concerns and questions. Legislators fromboth sides of the aisle have repeatedly stat-ed the need for objective health policyinformation in Colorado; the Hot Issuesprogram has been designed to fill thisneed.

Trading on Missouri’s nickname, theMissouri Foundation for Health’s ShowMe Series provides new information onhealth topics of significance to its servicearea and beyond, targeting both state legislators and the general public.Examples of issues covered in this series of papers include:

This event enabled top policymakers,health care experts, and community leadersto develop recommendations on how tohelp reduce and eliminate racial and ethnicdisparities in California and the nation.These recommendations emphasized theimportance of data collection, training culturally sensitive health care providersand peer educators to serve diverse com-munities, proactively funding andproviding access to prevention care ser-vices, and encouraging healthy lifestyles.

Foundations are also supporting organiza-tions whose primary focus is to conveneexperts, policymakers, and others on a regular basis. In Massachusetts, a coalitionof funders provides support for theMassachusetts Health Policy Forum, anorganization focused on bringing publicand private health care leaders together todiscuss critical health policy challenges fac-ing the state. Forums are convened at leastfour times a year.

Other funders target different audiences.For example, Arizona Health Futures, thehealth policy and education arm of St.Luke’s Health Initiatives, has a strategy forengaging the public at large in discussionof key health issues through both publica-tions and public meetings. Activities in2003 included a town hall meeting to discuss the challenges presented by theprojected growth in Arizona’s elderly population, development of a Web site toreview the impact of the state’s budget cri-sis on public health programs and services,and publication of policy primers on thepublic health infrastructure and integrationof behavioral health and primary care.


• a study of the impact of a single payertax-based system on current healthexpenditures in Missouri, which suggestedthat all Missourians could receive healthinsurance coverage for less than the nearly$30 billion spent on health care thatyear;

• an analysis of the economic and healthbenefits of the state’s Medicaid program;and

• an analysis of cost growth and healthinsurance coverage in the state.

At the national level, several foundationshave supported the National Health PolicyForum (NHPF), housed at GeorgeWashington University, to foster moreinformed government decisionmaking.NHPF serves primarily senior staff inCongress, the executive branch, and con-gressional support agencies throughpublications, meetings, and site visits.NHPF site visits give federal policymakersa firsthand look at the problems and suc-cesses of important health care programsand markets around the country. Theseone- to three-day sessions allow attendeesthe opportunity to gain valuable insight onhow communities or health care providersare dealing with issues in their local areas.The Robert Wood Johnson Foundationfunded NHPF to conduct a site visitfocused on private market dynamics andhealth quality improvement initiatives inCincinnati, Ohio. Among the issuesexplored were physician supply, incentivestructures, specialty hospitals, and informa-tion technology. Funders at the state andlocal levels have also supported these activities. The California HealthCare

Foundation and the Alliance HealthcareFoundation in San Diego jointly funded asite visit to southern California, where 25federal legislative and executive health poli-cy staff members were educated onmanaged care issues. The site visit includedmeetings with provider groups and man-aged care organizations to explore industrytrends and issues related to federally fund-ed programs and system gaps.

Public Opinion Polls

Gauging public opinion on specific healthtopics is often the first step in developingeffective solutions to complex health policyissues. As part of a continued emphasis onthe need to improve access and insurancecoverage, the Blue Cross Blue Shield ofMassachusetts Foundation funded RobertBlendon and his team of pollsters at theHarvard School of Public Health to surveyMassachusetts residents. The report, The Uninsured in Massachusetts: AnOpportunity for Leadership, presented information on current public perceptionsof the uninsured problem in the state, values underlying Massachusetts residents’views of the uninsured and solutions to theproblem, the most widely supported solu-tions, the willingness of the public to paymore taxes to assist the state’s uninsured,state residents’ views of the state of healthcare, and what these residents know andbelieve about the state’s uninsured problemand current state programs that aid thosein need. The survey found that most peo-ple in Massachusetts strongly believe thateveryone in the state should be able to getthe health care they need and support sev-eral proposals to expand health coverage(Blendon et al. 2003). The survey was


part of the foundation’s long-term goal ofinforming the public debate about how toprovide health coverage for the uninsuredin Massachusetts, and its findings havehelped shape the foundation’s subsequentwork on this issue.

Public Information Campaigns

To create broad public understanding andsupport for health policy decisions, advo-cates must be able to influence publicperception of their health issues. Educatingthe public and policymakers about thehealth implications of proposed policies isone of the tools foundations can use togarner support for promoting health. TheCalifornia Wellness Foundation (TCWF)in 1994, for instance, made a $4 milliongrant for a public education projectdesigned to increase the awareness andknowledge of Californians on the merits,background, and potential consequences ofa state ballot measure, Proposition 188.The measure proposed preempting localsmoking ordinances and replacing themwith a single, limited statewide ban thatallowed regulated smoking in most publicplaces. Proposition 188 would have hadthe effect of weakening tobacco controllaws throughout the state, resulting inhundreds of millions of dollars in increasedhealth care costs and adverse health out-comes, according to a nonpartisan study(Holton 2002).

TWCF’s policy goal was to make sure thatvoters understood both sides of the debatebefore casting a vote on Proposition 188.Early polling indicated that likely votersmisunderstood the initiative, with 70 per-cent favoring the initiative and thinking

that the measure would provide “toughstatewide smoking restrictions” (TheDemocracy Center 2004). The campaigndid not advocate for either position, butsimply laid out the facts as they appearedin the state’s official ballot pamphlet andurged voters to read this informationbefore voting. These facts included whofunded the measure (Philip Morris andseveral other tobacco companies) as well as who opposed it (such as the AmericanLung Association of California, theAmerican Heart Association’s Californiaaffiliate, and other leading health organiza-tions) (Holton 2002).

The foundation took extreme measures todemonstrate that the effort was a strictlynonpartisan, independent, educationalcampaign. Foundation staff steered clear ofthe actual campaign once funding wasapproved and kept at arms length from thedevelopment and content of the ads. Thegrantee consulted with the state’s FairPolitical Practices Commission for ad copy and other campaign materials (TheDemocracy Center 2004). The tobaccoindustry tried to challenge the ads, butbecause the foundation had covered itsbases and was within legal bounds, thechallenge was unsuccessful. The weekbefore the public education campaign,polls showed the measure winning. Withina week of the campaign’s launch, the num-bers reversed. Proposition 188 ended uplosing 70 percent to 30 percent, a hugedefeat for the tobacco industry, which put$35 million into trying to pass the mea-sure (Holton 2002).

In 2004, the debate surrounding marriagefor same-sex couples was a leading issue inthe presidential campaign. To help inform


The Web site continues to provide valu-able information past the 2004 election,and the foundation strongly believes thatencouraging greater civic involvementaround lesbian, gay, bisexual, and trans-gender issues is critical for any positive,lasting change to occur. In addition to initiating TurnOut, the foundation hasadded civic participation as a new programarea in its grantmaking guidelines and isemphasizing civic participation in its nonprofit training programs.

Media Advocacy

Media advocacy is a specific approach toinfluencing public policy or creating socialchange that involves strategically using thenews media to shape public opinion,mobilize activists, and influence decision-makers (The Health Communication Unit2000). It requires developing messages thatinclude both problems and solutions, andrecruiting media spokespeople who canwork with journalists on stories related tothe issue of concern. Because it focuses onearning access to the news media, ratherthan on paying for advertising time, it canbe a cost-effective strategy if sufficienthuman resources are available. Mediaadvocates gain access to news media bypresenting issues in ways that are newswor-thy, and therefore, likely to be covered bymedia outlets.

The media plays an important role inshaping public policy debates and layingout the decisions policymakers and thepublic must make. In today’s changing andcomplex health care system, journalists aretasked with covering a range of hot-buttonhealth issues, from prescription drugs tothe Medicare program, and making these

the debate on this controversial issue andencourage civic participation, the GillFoundation created TurnOut, a publiceducation campaign to let Americansknow about the inequalities faced by lesbian, gay, bisexual, and transgender people in their everyday lives. Elements ofthe campaign included groundbreakingtelevision and print advertising in Denver,Colorado, Tampa Bay, Florida, and Flintand Lansing, Michigan; national grassrootsmarketing; and an interactive Web site featuring key facts, two documentaryspots, and personal stories. Another campaign component included a TurnOutvoter mobilization toolkit that was provid-ed to more than 250 organizations aroundthe country to help them educate theircommunities about these issues and getout the vote among their constituencies.The campaign focused on the followingstatistics:

• Only 14 states prohibit employment discrimination on the basis of sexual orientation.

• Same-sex families are denied more than1,000 federal benefits that come withmarriage and, in 47 out of 50 states, theyare denied most of the state rights andresponsibilities that come with marriage.

• Partners in a committed same-sex relationship are denied Social Securitysurvivor benefits when one dies.

• Children of same-sex parents are deniedsurvivor benefits if the deceased parentwas not the biological parent or wasunable to obtain a second-parent adoption.


issues clear and accessible to the generalpublic. In 1993, The Henry J. KaiserFamily Foundation launched the KaiserMedia Fellowship in Health Program to helpjournalists and commentators keep thepublic informed about critical health issuesand the evolving health care system. Theprogram provides health journalists with ahighly flexible range of opportunities topursue in-depth projects related to healthpolicy, health care financing, and publichealth issues. Giving fellows time and travel opportunities to research specifictopics, the purpose is to help journalistsimprove the quality of the work they doand enhance their ability to explain thecomplex ethical, economic, medical, andpolitical aspects involved in their reportingon health issues.

Some 70 Kaiser fellows have been selectedsince the program started. Fellows areawarded a basic stipend of $55,000 for a12-month period, plus travel expenses.They are selected by a national advisorycommittee, which reviews fellowship appli-cations and interviews finalists (The HenryJ. Kaiser Family Foundation 2004).

Consumer Empowerment andCommunity Engagement

Consumer empowerment and communityengagement are among the many tools atthe advocate’s disposal. These elementsinclude educating consumers and commu-nities about the health care system, localhealth care issues, and the impact of healthsystem changes on their health, as well asbuilding a stronger decisionmaking role forconsumers in the system (CommunityCatalyst 2001). Engaging consumers putsa human face on the issues, a powerful tool

for advancing social change. Several foun-dations are funding activities to empowerconsumers to advocate on their own behalffor both broader health system changesand specific issues.

The Rose Community Foundation hassupported several organizations in its service area in support of communityengagement and consumer empowerment.The foundation was instrumental in thecreation of the Colorado ConsumerHealth Initiative (CCHI), a unified,statewide organization of consumers andadvocates whose goal is adequate andaffordable health care for all. CCHIencourages and develops leadership amongconsumers, brings together diverse organi-zations concerned with health care, andprovides information to the media andpolicymakers about real consumers’ healthconcerns.

The foundation also funded the MetroDenver Black Church Initiative (MDBCI),an organization that works from thepremise that the black church is the preeminent institution in the African-American community for strengtheningfamilies and enabling self-sufficiency. Inaddition to programs for youth, MDBCIseeks to alleviate the health disparities thatexist between the African-American com-munity and other populations. More than35 member churches and a host of com-munity partners provide health educationand health screenings to engage communi-ty members and promote active andhealthy lifestyles.

Foundations are also funding activities toempower consumers to advocate for them-selves on specific health issues. The


California Endowment, for example, fund-ed the Fresno Metro Ministry to trainlow-income consumers to be advocates forculturally competent care. Project activitiesinclude training and supporting more than1,000 low-income consumers to activelytake part in health care policy discussionsand activities; participate in neighborhoodroundtables to discuss health needs andidentify strategies for change; and meetwith key leaders from health provider orga-nizations and have direct discussions aboutlocal health care concerns, such as lack ofculturally competent staff, inconvenientclinic hours, and lack of services for theuninsured. Other objectives of the grantinclude developing and implementing apolicy agenda on at least four differenthealth issues; providing testimony at pub-lic meetings with the county board ofsupervisors, as well as press conferences;and encouraging at least 10 consumers tofight for seats on local advisory or govern-ing boards, such as the county mentalhealth board, hospital advisory boards, andother health care policy bodies.

Youth AdvocacyFoundations are also reaching out toyouth, who are often effective advocates.This is especially true when youth areallowed to identify the issues of concernand play a role in developing the proposedsolutions. Organizations with expertiseworking with this population group aregenerally more effective in this regard thanthose whose primary expertise is policy.Grantees without experience working withyouth often have difficulty giving up thecontrol necessary to take full advantage ofthe resources youth bring, thus making it afrustrating experience for both parties(Holton 2002).

The Liberty Hill Foundation funded theCommunity Coalition of Los Angeles, analliance of volunteer individuals and orga-nizations committed to organizing SouthLos Angeles neighborhoods, youth, andsocial service agencies. The goal of the pro-ject was to document the poor, and oftenunsafe, conditions of inner-city schoolsand advocate for increased funding forSouth Los Angeles schools. The projectequipped 60 students active in the SouthCentral Youth Empowered Through Actionprogram with disposable Kodak cameras,and sent them into their schools. Backedby photographic evidence, the studentsstaged a protest and quickly won a meet-ing with the school funding oversightcommittee. The student photographerspresented their evidence and as a result,the 127 schools in South Los Angelesreceived an additional $153 million worthof repairs. Just as importantly, the studentslearned firsthand the power of grassrootsorganizing.

Similarly, the Alliance HealthcareFoundation in San Diego, California hasfunded several projects to engage youth as advocates for social change. The foundation funded a pilot project to traininner-city high school students on healthissues affecting their community.Sponsored by the San Diego StateUniversity School of Social Work, the program used a consensus-based model toeducate and train students on becomingcommunity leaders and on advocating forsocial change and improved human ser-vices.

The Public Welfare Foundation, a nationalfoundation located in Washington, DC,funded the Earth Conservation Corps, a


group that has lost 12 of its youth mem-bers to gang violence or beatings in thepast decade. The organization discoveredthat the bald eagle, this country’s nationalsymbol, no longer nested in the nearbyAnacostia River because the water was sopolluted. It organized youth in the com-munity to sample the river regularly andadvocate to the appropriate authorities forthe river’s cleanup. Their efforts paid off,with the bald eagle now nesting in theAnacostia area. To document this achieve-ment, the foundation also funded a film,Endangered Species, about the bald eagle’splight in Anacostia as well as the youth’splight for survival in the same community.The footage includes the funerals of youngpeople killed by gang violence, but it alsoshows the bald eagles soaring and theyouth from Anacostia who have made it intheir communities (Langston 2004).

Building Advocacy Capacity

Advocacy requires infrastructure, andgrantmakers have learned that one of themost effective strategies for funding healthadvocacy is to invest in capacity-buildingactivities. Foundations are working tobuild advocacy capacity in their communi-ties by arming organizations with thenecessary tools and resources and by devel-oping the advocacy skills of direct serviceproviders, both individual providers andlarger health care systems.

Providing Information and ToolsFunders are investing in advocacy capacityby providing organizations with the infor-mation and tools necessary for engaging in effective advocacy. According to the

Strengthening Nonprofit Advocacy project,most nonprofit organizations do not fullyunderstand the basic limits on lobbying,the definition of what constitutes lobbyingunder IRS rules, and the legal opportunityto lobby with private funds (The AspenInstitute 2004). Foundations can play animportant role in ensuring that nonprofitorganizations have all the information necessary to exercise their legal rights toengage in lobbying and other advocacywork. Some foundations occasionally sendtheir grantees information about the regulations governing advocacy activities.7

Other grantmakers have gone a step fur-ther by providing potential advocates withthe tools necessary for launching effectiveadvocacy activities. The ConnecticutHealth Foundation, for instance, fundedthe Connecticut Health Policy Project todevelop the Health Advocacy Toolbox, aresource for individuals and nonprofitorganizations in the state of Connecticut.The toolkit contains resources and infor-mation on Connecticut’s budget process; a section on changing public opinion, with tips on public speaking, talking toreporters, and media advocacy; and aprimer on navigating the legislativeprocess, including an explanation of how a bill becomes a law, sample letters to policymakers, suggestions on calling or visiting legislators and their staff, advice for testifying at a public hearing, and evendirections to the state capitol building andlegislative offices. This Web-based tool isaccessible to anyone interested in developing effective advocacy skills, but isespecially targeted toward consumers andorganizations in the state that want to

7 A good source of information is Worry-Free Lobbying for Nonprofits, a publication from the Alliance for Justice.


TOOLS IN ACTION: A CASE STUDY IN EFFECTIVE ADVOCACY

A combination of any or all of the previously described strategies is often the key to successful advocacy change. This was certainly the case for Tenants’ and Workers’ Support Committee (TWSC), a local advocacy group first organized inresponse to the mass evictions of 5,000 low-income Latinos and African Americans from local neighborhoods. Based inAlexandria, Virginia—where many low-income jobs lack health insurance, and there is no public hospital or federally qualified community health center—the group used a combination of research and grassroots organizing to advocate for changes in private hospital policy.

TWSC had been hearing stories from community members about their experience with a local for-profit hospital,Alexandria Inova Hospital. Problems included a lack of access to translation services for Latino patients (a growing population in Alexandria) and issues related to medical debt among low-income patients. The organization decided tosupport those anecdotes with research, and together with The Access Project in Boston, Massachusetts, TWSC surveyed225 uninsured area residents. The survey was designed to provide a portrait of the experiences of the uninsured who hadsought care at the hospital. TWSC also examined hospital practices, using telephone inquiries and site visits to determinethe hospital’s level of outreach, public information, and staff familiarity with its free care policies and practices.

Survey findings revealed that of 225 respondents, 80 had incurred hospital medical debt. Those in debt reported thatdebt was a barrier to follow-up or further care. The survey also identified lack of access to translation services and bilingual materials as another serious barrier to care for Latino residents. The investigation of hospital practices uncoveredthat Alexandria Inova Hospital failed to inform individuals inquiring about hospital free care 67 percent of the time.Moreover, TWSC found that the hospital lacked brochures containing information about public insurance programs or its free care policies.

Armed with research, TWSC leaders brought 12 uninsured community members to tell their stories to top administra-tors, including the chief executive officer of Inova Health Systems, the parent company of Alexandria Inova Hospital. Theresearch findings, coupled with the personal stories of hardship, provided the tools for some improvements to hospitalpolicy, including the immediate freezing of 10 debtor accounts with the hospital and a series of meetings among its staff to address the issues of debt relief and cultural competence.

CONTINUING THE FIGHT

More, however, remains to be done, and TWSC is continuing to work with the community to advocate for improve-ments to hospital policy. While Inova Health Systems has implemented several changes to improve the culturalcompetence of its services, including increasing the availability of interpreters, progress has been much slower on improving the hospital’s charity care policy and resolving debt. After repeated requests and suggestions, hospital administrators provided TWSC with its current charity care policy, which uses federal poverty-level guidelines to determine eligibility for free- or reduced-price care and is irrelevant to the actual cost of living in Alexandria.

In addition to negotiating with the hospital, TWSC is working to decrease the probability of medical debt by working with city officials and community health coalitions to improve policies at the state and local levels for providing care to theuninsured. TWSC is a member of Alexandria’s ad hoc Access to Care Coalition, whose developing mission is to expandthe services and collaborative health planning effort in the city, including efforts to be designated as a medically under-served population by the Health Resources and Services Administration, a necessary step to receiving federal funding for a community health center (The Access Project 2004).


skills. The goals of the fellowship are tomake social justice a core professionalvalue for physicians and develop a cadre of advocates with expertise in achievingsystem or policy-level social change at thelocal, state, and national levels. During a12- to 24-month period, fellows work inpartnership with a U.S.-based advocacyorganization to address health and servicedelivery deficiencies caused by social issuessuch as racism, violence, environmentalhazards, income inequality, or inadequateeducation.

Similarly, The Dyson Foundation in NewYork sponsors the Dyson Fellowship inPediatric Advocacy, a program providingtraining for pediatricians in social andpublic policy, as well as legislative processesand institutional development and change.The program responds to the many serioushealth problems confronting children andtheir families, particularly those defined asat risk, and recognizes the growing needfor pediatricians to expand beyond theirtraditional clinical roles and become advocates for the children they serve. Thisfellowship program provides a two-yeartraining opportunity for two pediatriciansper year.

Supporting Specific AdvocacyCampaigns

Some funders provide support for specificadvocacy campaigns, either in addition toor in lieu of providing general operatingsupport to advocacy groups. TheConnecticut Health Foundation, for exam-ple, funded the Connecticut Oral HealthInitiative to advocate for improved oralhealth policy by identifying leaders, devel-oping policy briefs, conducting legislative

make a difference in their communities,but do not know where to start.

Developing the Advocacy Skills ofDirect Service ProvidersFunders are also supporting projects tobuild the advocacy and policy capacity ofproviders serving low-income communi-ties, which are often in a strong position tovoice what policies need to be improvedbecause of their interaction with con-sumers and their practical knowledge ofwhat works in today’s health care environ-ment.

Several foundations have provided grantsto health care delivery organizations todevelop advocacy know-how in order tocomplement the service delivery arm oftheir work. For example, the Blue CrossBlue Shield of Massachusetts Foundationprovided funding, through its CommunityAdvocacy for Change initiative, to strength-en the ability of community health centersto respond to health policy changes affecting health centers and patient accessto community-based services. Similarly, the Fannie E. Rippel Foundation provideda $500,000 grant to the Brigham andWomen’s Hospital to establish a hospital-based program in women’s health policyand advocacy.

Physicians are in an especially valuableposition to advocate on behalf of theirpatient populations and communities,given their respect from most policymak-ers. The Open Society Institute, the hub ofthe Soros Foundation’s network, sponsorsthe Soros Advocacy Fellowship for Physicians,a program that enables practicing physi-cians to develop or enhance their advocacy


STARTING FROM SCRATCH: A CASE STUDY IN BUILDING AN

ADVOCATE COMMUNITY

Even within state lines, advocacy capacity may not be evenly distributed. Whileoverall the state of California boasts an active and engaged advocate community, ithas been challenging to build the same infrastructure in the state’s Central Valley.Home to the state’s agricultural industry, providing produce to stores throughoutthe country, this region is also the setting for some considerable environmental hazards, including pesticides, dust from plowed fields, smoke from agricultural burning, urban air pollution, and hazardous waste dumps. Geographic isolation, coupled with a lack of political clout and legal resources, creates unique challengesfor cultivating environmental health advocates in this region.

To address this need, The California Wellness Foundation awarded the Center onRace, Poverty & the Environment (CRPE) a three-year, $120,000 grant for coreoperating support to develop and advance environmental health policies in thisregion. CRPE is the only environmental advocacy organization with an office in theCentral Valley. It serves low-income, rural communities by providing technical andlegal support, and working with agricultural communities to translate concern aboutenvironmental health conditions into effective information for policymakers.

The organization’s clients are predominantly Latinos living in rural areas and belowthe poverty line. With the foundation’s support, CRPE has worked with residents todevelop their confidence for civic engagement; nurture their grassroots organizingskills; and strengthen their voice in local public policies that affect the environmentalhealth of the places where they work, live, and play. Some successes include motivating county officials to examine the environmental impacts from a proposedethanol plant, ushering in a new level of transparency and openness from the boardof directors for a local water company, and organizing a public interest group thathas worked with the local state legislator to obtain clean water during the construction of new well (TCWF 2004b).

To build the capacity for policy analysis in this region, The California Endowmentawarded a five-year, $4 million grant to California State University, Fresno for thecreation of the Central Valley Health Policy Institute. The goals of the institute areto provide the Central Valley region with better informed community members,community-based organizations, and decisionmakers; a cadre of trained health policyleaders; strong and broad-based advocacy networks; and data and research specificto the region so that advocates and policymakers have the tools to influence policyand effectively advocate for systems change. The institute will collect, analyze, and disseminate research findings on pertinent health issues; develop and train community leaders on the health policy decisionmaking process; and create permanent, graduate-level coursework on health policy at the university.


Washington. Specific activities includedcreation of the Citizen’s Watch for Kids’Oral Health—including significant health,business, union, education, and children’sorganizations—bringing new voices tospeak up for children’s oral health; broaddistribution of campaign materials throughmultiple outlets; and development ofbroad consensus and support for publicpolicies to fluoridate water, ensure financial access to dental care (includingadequate provider payment for services),and protect state funding sources.

Promoting Collaboration andCoalition Building AmongAdvocates

Foundations can also play an importantrole by promoting collaboration amongadvocacy communities and facilitatingcoalition building among advocates andother stakeholders. As advocates face continuing battles to adequately fund andsupport health care programs in an era ofbudget deficits and competing priorities,promoting collaboration among advocatesis essential. Not only can organizationsoften do more together, collaboration provides an opportunity to share resources,learn from one another, and become energized about the work ahead.Supporting coalitions among diverse organizations also allows groups to sharestrengths and address weaknesses. Forexample, state policy groups may not havethe grassroots capacity needed to proposesolutions that are grounded in reality,while grassroots organizations rarely havethe resources to get engaged in state policyissues. Grantmakers can provide theresources and connection necessary forboth groups to work effectively together(Holton 2002).

trainings, expanding public awareness, anddocumenting the need for oral health ser-vices in the state.

The American Legacy Foundation fundedKids Involuntarily Inhaling SecondhandSmoke (KIISS) to develop a smoke-freeimplementation kit and CD to help ensuresmoke-free workplace laws are put intopractice in cities and states having suchlaws. KIISS will use these materials to edu-cate and train owners of restaurants andbars, and health advocacy groups. Thefoundation also funded the On the GroundSmoking Cessation and Prevention Project,an effort to reduce smoking among collegestudents, strengthen campus anti-smokingpolicies, and raise public awareness in sur-rounding communities. The foundation isintially working with three historicallyblack colleges and universities (HBCUs) inNorth Carolina; if successful, the founda-tion hopes to expand its work to HBCUsnationwide. Specific initiative componentsinclude a peer health advocate program totrain students as counselors for smokerstrying to quit; a public education campaign that will communicate thehealth risks of tobacco use through popu-lar radio stations; data collection on thefrequency of tobacco advertising and retailsales in minority communities, coupledwith community forums to share the findings; and a Web-based component,with resources and tobacco cessation curriculum materials.

Another example of support for a specificadvocacy campaign is the work of theWashington Dental Service Foundation infunding development and implementationof a sophisticated effort to improve theoral health of children in the state of


Over time, grantmakers have learned a fewthings about effective advocacy collabora-tions. First, collaborations need a dedicatedstaff person with responsibility for keepingthe collaboration going, because staffmembers within each collaborating organization have their own jobs, oftenwith no time to devote to this process.Second, grantmakers can be integral inidentifying opportunities for collaborationthat each organization by itself may nothave imagined. While forced collaborationis never a good idea, foundations can helporganizations with the same goals keepworking together. The California WellnessFoundation, for example, funded a collab-orative effort around implementation of anew state department of managed care.Several organizations had approached thefoundation separately to fund individualimplementation efforts. The foundationgathered them all together in one roomand asked them to develop a campaignthat could be implemented in collabora-tion. In the end, the foundation fundedeach organization for a small amount andthen created a larger pot of money to sup-port collaboration, with the organizationscooperatively deciding how to best use thisfunding (Holton 2004).

Focusing on a common purpose can unifyand strengthen different constituenciesthat share the same goal. This was the casein New England, where several funders(including The Boston Foundation andThe Jessie B. Cox Charitable Trust) pro-vided funding to hold together a multistatecampaign to raise tobacco excise taxes. Thecampaign was the work of the Alliance fora Healthy New England, a coalition ofadvocates for health care access and tobacco control and health care providers.

Five of six state coalitions won sizable taxhikes in 2002 legislative sessions. In everystate, this advocacy effort resulted in pro-tecting existing programs or earmarkingfunds for efforts to improve health careaccess and fund tobacco prevention andcessation activities (Community Catalyst2002).

Foundations are adding to their traditionalfunction as grantmakers the role of con-veners and catalysts in their communities.The Consumer Health Foundation(CHF), for instance, has worked to fosteralliances and build critical partnerships inits community. CHF funds and staffs sev-eral coalitions throughout the Washington,DC metropolitan area whose activities arealigned with the foundation’s mission. For example, the foundation is heavilyinvolved with the Regional Primary CareConversation, a group of local primarycare associations, public health agencies,health care advocates, and funders workingthroughout the region to collaboratearound operational issues such as information technology, organizationalcapacity building, health advocacy, andsystems reform. Participants meet everytwo months.

Foundations are also working to buildbridges and strengthen relationshipsamong existing advocacy leaders, as well asemerging leaders. In 1999, The CaliforniaWellness Foundation began hosting anannual two-day retreat for advocates work-ing on increasing access to health care forthe uninsured. The goal was to help builda stronger sense of community amongadvocates, provide them an opportunityfor strategic thinking, and identify oppor-tunities for collaboration. This retreat hasbecome an important forum for discussing


Supporting Sabbaticals forNonprofit Leaders

Leaders in the nonprofit sector often workunder conditions of unrelenting stress,with little time for rest and rejuvenation.Unlike those in the for-profit sector,burnout and turnover of these individuals

common agendas and helping build rela-tionships among the many organizationsworking on the issue. A few years into theprogram, the foundation invited partici-pating organizations to bring an emergingleader to these retreats, in recognition ofthe need to build and foster the next gen-eration of advocates.

PRACTICE WHAT YOU PREACH

Just as foundations are encouraging their grantees to collaborate and work togeth-er, grantmakers have learned that, particularly in funding policy and advocacy,collaboration among colleagues is key to effective grantmaking in this area. Whilefoundations often look for opportunities to fund something unique, and where thefoundation can place its mark, this attitude is counterproductive to policy andadvocacy efforts (Hogan 2004).

Because advocacy organizations often rely on soft money, a diversified funding baseis critical to their protection and sustainability. Working together, grantmakers arebetter able to support these organizations for the long time it will likely take formeasurable positive policy change. By partnering, each funder can comfortably sup-port one important facet of the organization’s advocacy work, yet still get yearlyreports of its unique contribution. Moreover, foundations are able to leverage theirindividual investments and power through different contributions from sister foun-dations with the same specific policy goals (Hogan 2004).

National foundations investing in policy change efforts can also benefit from collab-orations with local and state grantmakers who understand the local and statepolicy dynamics from first-hand experience. Local and state funders should notunderestimate their contributions to these partnerships; having a local perspectiveincreases the likelihood for realistic policy change goals and ultimately, success.National funders have also learned that working with a local partner facilitates rela-tionships with local policymakers, community and advocacy groups, and other keystakeholders.

Finally, local and state health funders are turning to their regional associations ofgrantmakers to find multipronged solutions for addressing issues that cross thehealth boundary, such as the environment, children and families, housing, and edu-cation. These local collaborations may include corporate funders that are betterable to make the case for funding advocacy when they are part of a partnershipwith other foundations (O’Bryon 2004).

“When we talk about some

of the pressing needs that

are jumping out in the next

few years, we’d be saving a

lot of resources, time, and

energy if we could bring our

brainpower together, come

up with a collective plan,

and go back and implement

it. It takes coordination,

collaboration and

partnership.”

LEO CANTY,

CONNECTICUT HEALTH

FOUNDATION


case on the merits of advocacy for improv-ing funding for specific health issues,grantmakers point to the potential forleveraging philanthropic dollars in sup-porting advocacy initiatives. Saving even 1percent of the state budget on health carethrough advocacy efforts can translate intomillions of dollars toward essential, directservices. This period of shrinking budgetsand cuts in service delivery at the state andlocal levels is an ideal time for grantmakersto consider increasing their support foradvocacy and public policy to complementgrants for direct services (Carson 2003).Philanthropic funding may also enableorganizations to leverage funds from othersources. The Prince George’s CountyHealth Action Forum in Maryland wasable to leverage a number of small founda-tion grants to build the capacity needed tosuccessfully acquire funding in the amountof $2.2 million over five years (Quinton2004).

An anecdotal example illustrates the bene-fit of complementing direct services withsupport for advocacy work. In 1984, thelocal Alzheimer’s Association chapter thatserves the Washington, DC metropolitanarea had a dilemma that most organiza-tions would crave; the mostlyvolunteer-run group, which had a yearlybudget of less than $25,000, received$140,000 in gifts from local federal government employees. The money came with few restrictions, and the onlyquestion was how to spend it. Initially,most board members wanted to give themoney either to other groups or to indi-vidual Alzheimer’s patients. But as theorganization’s leaders reflected on the long-term needs of Alzheimer’s patientsand their families, they recognized the

can have a detrimental impact on the communities they serve. In an effort torecognize and sustain dedicated leaders,several foundations are funding sabbaticalsto give these people the opportunity toreplenish their energy and renew theircommitment to the community. Inspiredby The Durfee Foundation’s Los AngelesCounty sabbatical program, The CaliforniaWellness Foundation launched its ownstatewide sabbatical program in June 2003,designed to support and rejuvenate leadersof California health service organizations.The program provides $30,000 each to sixleaders annually, as well as up to $5,000for their organizations to support the pro-fessional development of staff memberswho take on extra responsibilities in theabsence of sabbatical recipients.

Evaluating Policyand AdvocacyGrants

Perhaps the greatest area of concern tograntmakers is the ability to evaluate grantsmade to support advocacy, both individu-ally and collectively. As with any long-termstrategy, measuring the final outcome ofadvocacy work can be daunting. But justas grantmakers do not shy away frombroader societal issues such as eliminatingpoverty or disparities in health, grantmak-ers need not shy away from advocacy.

First, supporting advocacy can protect orincrease public funding for the issuesgrantmakers care about. While it is difficult to make a rigorous cost-benefit


need to complement this strategy. Givingfamilies money to help pay for badly need-ed, short-term respite care was a concreteway to help people; however, devoting theentire $140,000 to this approach wouldonly buy about one hour of care per familyper year. Thus began the organization’sentry into the policy arena.

After lengthy discussions about the organization’s ability to lobby, a part-timeperson to lobby at the state level was hired.Over the years, that lobbying has paid off.The most concrete result was passage of alaw that subsidizes respite care for familiesof Alzheimer’s patients, as well as individu-als with a similar, functional disability.Previously, only individuals with physicaldisabilities were eligible for subsidies. Thislaw has provided about $1 million a yearin respite subsidies for families who couldnot otherwise afford this care. So the orga-nization learned, over time, that investingsome of that $140,000 in lobbying hasleveraged more resources for Alzheimer’sfamilies than devoting all of that money todirect subsidies (Charity Lobbying in thePublic Interest 2001).

Second, influencing public policy is along-term process and should be evaluatedas such. Advocacy and public policy are nodifferent from other types of grantmakingwhere it is difficult to make a definitiveconnection between a single grant andimproved health outcomes. Health out-comes of specific projects are relatively easyto measure in a fairly short time, such aswhether a prenatal outreach program hasbeen able to reduce the number of womendelivering babies with inadequate prenatalcare. Long-term and systemic change,however, traditionally has been more difficult to track and attribute to specific

health outcomes; the life cycle of an individual grant or funding initiative cancomplicate this and make precise evalua-tion virtually impossible (David 2002).

Evaluating policy work thus requires bothshort-term and long-term measures. In theshort term, funders and their grantees candefine and measure key stepping stonesneeded to achieve ultimate policy goals,because significant policy changes rarelyoccur without them. The public policycontinuum is helpful in this regard (seeFigure 1 on pg. 2). In the short term, itmay not be possible to fully evaluate thefinal outcome. But it is possible to assessthe components of the continuum, all ofwhich are needed to move the policy agenda (Holton 2004). This involves having a clear and realistic model of whateach grant will achieve and working withthe grantee to devise steps toward thatgoal. For example, The Pew CharitableTrusts uses benchmarks to assess its policy-related grants, such as how manylegislators speak out on a specific healthissue, how many people were exposed to acertain message, or how many newspaperscovered the topic (Abernathy 2004).

Grantmakers have to learn which approachis right for their foundation and whatquestions to ask of their grantees andthemselves. According to Ruth TebbetsBrousseau, director of evaluation and organizational learning for The CaliforniaWellness Foundation, some of the ques-tions the foundation asks in regard to itsoverall grantmaking in public policyinclude what policies were changed, whatis the role of different types of grants ininfluencing policies, and are some strate-gies more effective than others or is a


combination most effective? Finally, for allgrants, timing is a critical issue that influ-ences success and failure. This is especiallytrue of policy grants, so the foundationconstantly evaluates whether it can bemore strategic in timing its grants effec-tively (Brousseau 2004).

Lessons Learned

Over the years, funders have learned notonly which tools and components are nec-essary for any effective advocacy effort, butmore importantly, how to apply these toolsin their own grantmaking. By sharing the

following reflections on foundation support for advocacy, hopefully morefoundations will explore the potential offunding in public policy to enhance theirgrantmaking goals.

• Core operating support, versus program-specific funding, provides importantflexibility for advocacy grantees. Giventhe inherently unpredictable nature offactors that influence the politicalprocess, it is important that advocacyorganizations have the capacity torespond quickly to windows of opportu-nity to advance their policy agendas.Core support grants enable grantees totake advantage of such opportunities andgive them the flexibility to change.

EVALUATING PUBLIC POLICY GRANTS

As more foundations become engaged in public policy and make more grants inthis area, grantmakers are developing and sharing their knowledge about the fac-tors that can influence the success of policy grants and their approach to evaluatingthis work. For example:

• Policy changes do not happen overnight. It is important for the funder and thegrantee to be realistic about the time it takes to change policy. It is frequently along-term process subject to multiple variables, many of which are beyond thecontrol of the grantee. For example, it took six years for The California WellnessFoundation’s Violence Prevention Initiative grantees to achieve their goal of a stateban on the production and sale of Saturday night specials. The best granteesknow how to use the media and grassroots to keep an issue before the publicand educate policymakers until action is taken.

• It can be difficult to attribute a policy achievement to the actions of specificgrantees. Grantees are always eager to claim credit for a policy change. But frequently, such change is the result of the combined effort of several organiza-tions and political factors outside the control of the grantees. Sometimes the fullimpact of the work of a grantee may not be realized until years after the end ofthe grant (Holton 2002).

• In evaluating ultimate policy and advocacy outcomes, it is unrealistic to attributewins to any one foundation. It is more important to assess what the grantee isaccomplishing, rather than knowing that the foundation’s dollars were used toaccomplish the outcome (Hogan 2004).


mutual interest. Seek out opportunitiesfor individuals to come together, learnfrom one another, and share their strate-gies for successful advocacy. Funders canbe instrumental in forging networks,whether they be across the country or intheir own backyards (Vega-Marquis2003). Partnering with all possible inter-est groups and sectors of the communitywill strengthen the collaborative whilestretching the foundation’s comfort zone(Riedel 2004).

• Decide up front what the foundationeventually wants to accomplish, but thenbe open to the tools and strategies thatare used to accomplish this goal.Remember, there is not one right way;in fact, such a mentality may be a signof a top-down (versus grassroots)approach (The Philanthropy Initiative,Inc. 2004).

• Keep in mind that mounting and sustaining advocacy and policy changeinitiatives requires long-term commit-ments and can involve large investmentsof foundation resources and time. Beprepared to invest in these efforts overthe long haul, which may mean any-where from 5 to 15 years (Riedel 2004).

Conclusion

Advocacy is one of many philanthropicstrategies that grantmakers have at theirdisposal to improve the health of individu-als and communities. By itself or intandem with funding for direct services,advocacy is a powerful strategy to add toany grantmaking portfolio. Advocacy can

• Demystifying the policy process is key to engaging community members inadvocacy. For most people, the policy-making process is a mystery that makesparticipation intimidating. Foundationscan do their part by underscoring theimportance of policy to achieving long-term goals and helping grantees developeffective approaches.

• Engaging community members in advo-cacy has long-term benefits. Changingpublic policy can be an empoweringexperience. Once community membershave experienced a public policy success,they are more likely to stay engaged inefforts to improve their communitiesand hold policymakers accountable.

• An important ingredient of a successfuladvocacy effort is engaging the grass-roots. In this era of term limits,policymakers are less likely to haveknowledge of the issues. Thus, it is particularly important that they hearfrom their constituents. Real people puta face on the issues and, coupled withpertinent data, research, and analysis,can be the driving force for changingpolicy.

• Be careful the messenger does notdetract from the message. It is importantwhen giving grants to advocacy organi-zations to know what their reputationsare with policymakers. If policymakershave had a bad experience with agrantee, they are unlikely to be receptiveto the message (Holton 2002).

• Connecting grantees and encouragingshared learning facilitates the creation ofa network of networks, which can helpfoster a movement around issues of


leverage limited resources, promote sys-temic change, and respond to the publicneed.

Health grantmakers play an important rolein supporting advocacy by ensuring that allvoices are heard in public policy decisions;information is available to policymakers,opinion leaders, and the public; and thoseworking on behalf of the underserved havethe opportunity to interact and learn fromone another. Grantmakers who choose notto engage in this work forfeit an opportu-nity to promote long-term change in theircommunities and make a broader impacton the lives of individuals, communities,and the nation.

References

Abernathy, Pauline, The Pew CharitableTrusts, personal communication toGrantmakers In Health, August 6, 2004.

The Access Project, “Stories from theField: Negotiating for Free Care andCulturally Competent Services in Wealth City’s Only Hospital,”<http://www.accessproject.org/pr_Tenants.htm>, September 23, 2004.

Alliance for Justice, “The 501(h)Election—What Does it Mean?”<http://www.allianceforjustice.org/foundation/technical_resources/501h_election/index. html>, October 18, 2004a.

Alliance for Justice, Legislative Visits byPrivate Foundations (Washington, DC:January 2004b).

Alliance for Justice, Support Grantees ThatLobby (Washington, DC: 2002).

Aron, Nan, “Advocacy’s Efficacy,”Foundation News & Commentary 45(4):36-37, July/August 2004.

Asher, Thomas R., Myth v. Fact:Foundation Support of Advocacy(Washington, DC: Alliance for Justice,1995).

The Aspen Institute, “Lobbying andAdvocacy by Nonprofit Organizations:Rethinking the Legal Constraints onNonprofit Voices,” Snapshots No. 34(Nonprofit Sector Research Fund, May2004).


Community Catalyst, “BuildingCoalitions: Lessons from the Alliance for aHealthy New England,” States of Health12(1):Winter 2002.

Community Catalyst, Our Theory ofChange (Boston, MA: November 2001).

David, Tom, “An Approach toEvaluations,” Evaluations and LessonsLearned from Our Grantmaking(Woodland Hills, CA: The CaliforniaWellness Foundation, 2002).

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